Questions discussed in this category
Is there a role for ctDNA?
The patient declined palliative measures only and is motivated to receive treatment
PUMP-2 trial combined FUDR via HAIP with gemcitabine and cisplatin, no immunotherapy was on the protocol.
Ampullary carcinoma is not in the NCCN guidelines. Please address not only the role for therapy but the optimal regimen (i.e. Gem based, vs mFOLFIRINO...
Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?
Post-operative surgical course was complicated by anastomotic leak, septic shock, candidemia, wound infections, PE & DVT. Now recovering well.
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
Would you treat as cholangiocarcinoma with a gemcitabine/platinum regimen or would you use a more HCC regimen like atezo/bev or durva/trem?
Is there data on neoadjuvant chemo-RT or chemo in this setting?
Was this monitored in TOPAZ-1?
Assume the patient is young and active.
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
And if so, which one? Does nodal status affect your decision? Is there any evidence for ctDNA in this space?
Would chemoRT be preferred over surgery if there is LVI or PNI?
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
If triplet chemotherapy is likely too morbid, would you prefer neoadjuvant chemoradiation per CROSS in this setting?
Or do you start with systemic therapy and then reassess?
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
Would you use nivolumab or a taxane? Is the data from the ATTRACTION-3 trial with an all-Asian patient population applicable to practice to the US pop...
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
What are your absolute & relative contraindications for bevacizumab use?
Nivo 3 + Ipi 1 Q2W x3 then Nivo alone? Or Nivo 3 Q2W & Ipi 1 Q6W until POD or toxicity? Or other?
Are there factors which would make you more likely to use atezo/bev vs durva/treme vs TKI?
How would the duration of 5FU infusion impact response?
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
Would portal hypertensive gastropathy or colopathy sway you away from using it?
Given the recent update from the NAPOLI-3 trial presented at GI ASCO 2023, the two regimens appear to have similar OS.
Would you ever consider this approach for an initially polymetastatic patient?
And if delayed, should chemotherapy be started?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
If so, what regimen? At what point is it safe to start chemo in a freshly transplanted liver?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
And is there any role in utilizing FGFR2 inhibitors in first line setting?
The PROOF trial utilizing Infigratinib in first line was stopped after the...
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
Would you offer adjuvant nivolumab?
Is there data to support this approach?
Do you continue atezo alone if responding or switch to an alternative therapy such as dual IO or TKI? What about if the patient were experiencing subt...
Would the grade of the lesion affect your decision?
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
Patient refuses further mFOLFIRINOX but may be open to less aggressive regimens. Is there any role for PARP inhibitors?
What factors might play into this decision?
Is there a role for circulating tumor DNA in this setting?
And if so, would you offer it pre or post-metastasectomy? Would time to recurrence or ctDNA play a role?
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
Especially as the study was done before the adoption of total neoadjuvant therapy
Would you treat with immunotherapy ?
Or offer resection followed by adjuvant therapy?
Would you only give three cycles with radiation, or are you adding two more cycles of FOLFOX afterwards?
Does DOTATATE scan results/burden of disease change your preference?
Would you offer single agent immunotherapy or chemo-immunotherapy with gem/cis durva/pembro?
Would you consider dose reduction versus adding C-GSF?
Would you approach with curative intent with locoregional treatment or systemic treatment alone?
PD-L1 CPS of 1, no other actionable mutations except HER2.
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
Is liquid biopsy helpful? Would you treat if this shows somatic mutation?
The ICI adjuvant data we have so far doesn't clearly separate MSI-H disease from all comers.
Yaeger et al., PMID 36546659
Would you offer as first line treatment mitomycin/5FU with radiation or single agent immunotherapy?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
Aside from chemoradiation, are there situations in which you might consider this alternate schedule?
Or use baseline PET followed by serial MRI/CT for monitoring?
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
How did the SWOG 1505 clinical trial influence your clinical practice?
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Is there any data to support the use of immune checkpoint inhibitors either preoperatively or even definitively, similar to rectal or gastric?
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
D-TORCH compared topical diclofenac to placebo
Staging/pre-op MRI only showed mild non-specific thickening.
Exploratory analysis of the MAGIC trial suggested perioperative chemotherapy was detrimental in this subset of patients. Has availability of IO altere...
What factors do you consider - perforation, size?
And is it different when using pembrolizumab or a combination of ipilimumab/nivolumab?
Do you add VEGFR/EGFR antibodies? Or switch to another regimen?
Taking into account follow up from NEO, OPERA and other organ preservation trials?
4 months of Neoadjuvant GAP resulted in conversion from unresectable to resectable.
Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?
Please specify how your institution is allocating resources now or will be soon.
> 30s, female with metastatic colon cancer. Presented with a headache. Metastatic hemorrhagic mets per MRI 10/2022. Had radiation. Kras mutated, Br...
How do you reconcile the differences between the two studies?
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
Would sidedness matter? Do you use ctDNA assays to evaluate for acquired RAS mutations to guide this decision?
Does the patient's young age affect your decision when applying data from the IDEA collaboration?
Instead of FOLFOXIRI and bevacizumab as per TRIBE trial
Do the overall survival results of PARADIGM presented at ASCO 2022 change the standard of care?
Would you advocate for a targeted gene approach or a fully comprehensive NGS panel?
Would your recommendation change in a patient having pain from disease and you wanted a quick response?
Would you recommend pembrolizumab prior to surgery? Or after? Is there a role for FOLFOX?
E.g. loss of PMS2 expression by IHC only but MSI stable by PCR.
If so, how long would you treat?
Would you use a different chemotherapy regimen than mitomycin/5FU?
Are you more likely to consider a trans-anal resection?
And if so, would you offer FOLFOX or Immunotherapy?
Would you offer EGFR inhibitors as second line?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Based on CheckMate 577?Is DFS endpoint sufficient to establish SOC or is OS benefit needed?
Is there a role for ctDNA in this case? Would the approach change if the patient is MSI-H?
Would you continue FOLFOX or switch to another agent?
KRAS WT, MSS, no targetable mutations
Specifically, would you consider either neoadjuvant or adjuvant immunotherapy in this setting, or only after recurrence?
Do we wait and watch vs start treatment based on ctDNA results?
Given that pembrolizumab/trastuzumab with chemotherapy is new SOC for metastatic disease, how would you approach those with recent fluoropyrimidine + ...
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Patients with deficient mismatch repair (dMMR) and microsatellite instability high (MSI-H) harbor high tumor mutational burden which tends to have fav...
Patients with gastric cancer can acquire new targetable mutations on progression. This could aid in additional treatment options in this group which t...
What other molecular tests do you routinely order on such tumors?
NCCN discusses targeted therapies (Everolimus) but also Temodar / Xeloda combination.
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
Do you rebiopsy or use a liquid assay?
Are there factors that would lead you to select either ramucirumab +/- paclitaxel vs T-Dxd vs chemo?
If so, what assay would you use in this population?
Do we have data on TMB/PDL1 status of long-term survivors?
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
No actionable genetic alterations were identified for this patient. Would you consider FOLFOX + durva, or even single-agent durva?
Would you use immunotherapy based on the TOPAZ trial?
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
TOPAZ-1 trial allowed for up to 8 cycles of gem/cis. Were there differences in chemotherapy duration/# cycles between treatment groups? Does use of du...
No preop therapy; dMMR in poorly cohesive and mucinous carcinoma component, pMMR in tubular adenocarcinoma component
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
Would you give additional treatment after surgery?
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Is there a difference in efficacy if dose is given later point during the course of therapy?
How would you balance the OS benefit from TOPAZ-1 with the risks of immunotherapy in this or other high-risk populations?
How do you sequence systemic treatment options for in patients with Child's Pugh B (or greater) in context of IMbrave150 and HIMALAYA?
When do you in...
Is data sufficient to adopt this as the new standard of care?
Can you comment on the reported regional and race-based variations in outcomes? ...
Any adjustments in terms of elective nodal coverage?
Do you proceed with chemotherapy alone, neoadjuvant chemoRT, or definitive chemoRT? How do you communicate treatment intent to the patient?
Would a negative dotatate PET change management for a patient for whom you were planning to start SSAs?
How reliable is somatic testing to detect an underlying germline predisposition?
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Would you extrapolate from the DESTINY-CRC01 study, even though RAS/RAF mutations were excluded?
For this example, Ki-67 of 80, MSS, low TMB
Patient with initially stage IIIC right sided colon cancer s/p resection found to have metastatic disease prior to starting adjuvant therapy. MSI-H an...
If radiation is indicated, what dose would you use?
Multiple positive nodes
Do you offer more chemotherapy during this time interval?
Do somatotatin analogues work in this scenario?
Do you drop or adjust the temozolomide at any point, or rather continue to progression as long as temozolomide is well tolerated?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Would you consider switching to a different regimen?
Would you consider the BEACON regimen (i.e., encorafenib/binimetinib + cetuximab) in this setting?
Which patients would you recommend active surveillance alone, a less morbid procedure such as enucleation, or a Whipple surgery? How does age influenc...
Total neoadjuvant therapy (TNT) included FOLFOX x 4 months and concurrent chemo-RT
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.
If you do not use prophylaxis, what skin care strategy do you employ?
Would you give trastuzumab every 2 or 3 weeks, pembrolizumab every 3 or 6 weeks?
Would you debulk with neoadjuvant therapy to achieve resectability?
Would you consider gem+Abraxane to avoid FOLFIRINOX toxicity in a small, node-negative tumor?
Residual GEJ mass and progression in local lymph nodes after carbo+taxol chemoRT without distant metastases.
If so, would you adjust 5-FU dosing?
Would your thinking change if the patient continues to be NED after an unplanned chemo break, e.g. for insurance issues?
Is it necessary to test CPS given the FDA approvals are not contingent on CPS %?
If you do test, do you check 28-8 (nivolumab), 22C3 (pembroliz...
Would you use reduced dose chemoimmunotherapy, single agent chemotherapy, or single agent immunotherapy if the patient is unlikely to tolerate full do...
Do you view CPS < 1% or 1-4% separately? Do you view the incremental benefit of adding immunotherapy still advantageous given relatively poor outco...
Do you go by FDA approval alone, or incorporate other data into your treatment decisions? How do you view updated recent presentation of CM-649 ...
Are there meaningful differences in the CHECKMATE 649 and KEYNOTE 590 studies to guide this decision?
Previously untreated
What combination of fluoropyrimidine, PD-1 inhibitor, or trastuzumab do you use?
Are there contraindications to drugs like oxaliplatin or abraxane?
Does chronicity or severity of the patient's underlying symptoms play a role in yo...
KEYNOTE 811 showed improved response rate with the addition of pembrolizumab, but very few patients in this study had low PDL1.
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Would you always offer an FGFR inhibitor as second line therapy in these patients instead of a second line chemotherapy regimen?
If an older patient is only fit enough for single agent fluoropyrimidine therapy, would you prefer to give this neoadjuvantly or adjuvantly?
Would you ever consider adjuvant chemotherapy rather than adjuvant immunotherapy after the publication of the CM-577 results? If so, in which pop...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Would you recommend 6 months of FOLFOX or just surveillance?
Pathology details: 75% high grade large cell neuroendocrine tumor of the cecum (20-30 mitoses per 10 hpf, Ki67 75%) and 25% adenocarcinoma. Patient ha...
G1 neuropathy and G3 neutropenia were observed with cycle 12 FOLFOX + bev.
Would you reintroduce oxali at a lower dose or switch to irinotecan+EGFRi ...
What about for a patient with complete radiographic response who declines surgical management?
If you had a patient with otherwise average risk stage 2 colon cancer but had signet ring or mucinous components to their pathology, would this sway y...
Of note - the tumor tissue biopsy NGS did not show KRAS or BRAF mutations. Microsatellite stable. Patient received first line FOLFOXIRI + Avastin .
For patients who have already undergone trimodality treatment, what time frame do you consider for adjuvant IO?
This involves the primary site responding but progression with new bone marrow involvement with resulting cytopenias.
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
Do you worry about fluoropyrimidine resistance with concurrent chemoRT? Is there any role for neoadjuvant immunotherapy?
What factors would influence your approach?
Are there other treatment variations by clinical subsets (eg tumor location, histology, stage II vs III, other biomarkers) seen in CM577 or other data...
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
Do you add on additional cycles of 5-FU/capecitabine to go beyond 3 months of treatment? Or would you stop at 3 months of therapy, dropping the oxalip...
Would the etiology of HCC affect your decision, e.g. non-viral hepatitis since less benefit was shown for this group in IMbrave150?
Ki-67 > 95%, PET-CT negative for any additional disease.
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
Would your decision be influenced by whether a pathologic complete response was attained?
The patient was started on a beta blocker, as this is standard in the area.
Would you consider using infigratinib after progression on pemigatinib?
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
What therapy would you offer if the patient had a baseline grade 2 neuropathy?
What determines duration of therapy in patients who achieve stable disease or no evidence of disease on imaging?
Is there any role for radiation in t...
https://pubmed.ncbi.nlm.nih.gov/34077237/
Would you extrapolate treatment from the paradigm of anal SCC?
Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...
Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...
Does your decision for 3 vs 6 months of treatment change for low risk stage III colon cancer?
Patients can develop sensory and motor symptoms such as paresthesias, jaw/facial pain and stiffness, cramping and twitching, ptosis and vision changes...
Biopsy of other sites is more consistent with carcinoid tumor.
eg LVI/PNI, poorly differentiated? If so, what regimen and for how long?
Has the recent approval of atezolizumab/bevacizumab impacted your decision making?
Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...
Is there a subset of patients you would avoid neoadjuvant CRT and operate first?
What would you offer in the setting of bulky liver metastases?
This patient had a Ki67 of 27%. However, the inclusion criteria for the NETTER-1 Trial was Ki67<20%. Would Lutathera be an option if labs are withi...
Does it differ in the curative vs palliative setting? Specifically thinking about adjuvant CAPOX in a patient with a BSA of 3. ~400 mg of oxaliplatin ...
Bulky hepatic metastasis
Benefit of oxaliplatin in patients >70 years of age is not proven and only 5FU/capecitabine in a MSI-H tumor is of questionable efficacy. What woul...
Would you use a small cell regimen over a more traditional FOLFOX-esque approach?
Would you offer low dose or standard dose aspirin instead?
Assuming all other factors are favorable (pT1-2, TME, negative margins).
Is there a threshold of when you would use chemo/radiation?
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 ...
If you do test, do you have a preferred testing method?
If so, do you avoid pegfilgrastim given that <12 days will lapse between its administration and the next cycle?
In GEJ or gastric cancers, do you routinely image after surgery, prior to resuming systemic therapy?
If so, how long do you wait after surgery prior to imaging to avoid post-operative findings?
How do you assess the risk of complications from including bevacizumab vs the known benefits of including it with chemotherapy?
Would you try atezolizumab/bevacizumab or switch to a TKI?
i.e. CA 19-9 >100
When would you consider gemcitabine/abraxane as an alternative treatment?
Would chemotherapy alone suffice? Repeat biopsy and EUS were negative for residual disease.
Specifically, would you consider incorporating immunotherapy in this setting?
What is the risk of perforation / fistulization?
No high risk features such as: lymphovascular invasion, perforation, or involved margins
Does the advent of more effective therapies like peptide receptor radioligand therapy (PRRT) and capecitabine and temozolomide (CAPTEM) dampen enthusi...
For example in a patient with a history of PE?
i.e. EGD surveillance for varices?
What parameters do you use to decide to treat beyond progression? Is there any efficacy data from this specific study subgroup in IMbrave150?
ex. VEGFR2 expression, inflammatory signature, PDL1, etc.
Do you continue atezolizumab alone? Would you avoid anticoagulation?
Patient with ECOG 0-1
Would you consider adjuvant chemotherapy?
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
Do you screen even asymptomatic patients?
Would you use FOLFIRINOX as in Prodige 23 or FOLFOX as in RAPIDO?
exam is + for ascites
Especially if the patient had advanced N3 disease and is reluctant to pursue surgery?
When would you consider use of ctDNA to help with this decision?
Or would you consider IO agent be given only after progression on platinum + fluoropyrimidine?
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.
Both ARTIST and Inte...
Patient had a solitary lung metastasis
For example, a FANC mutation
No known cardiac risk factors
Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?
The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...
Liver and skeletal metastasis with no disease in the lung.
MRI? Endoscopy? Physical exam?
Is there evidence for radiation therapy in this setting?
What are there most evidence-based options?
What is the added benefit of Chemo-RT vs RT alone?
How would the sidedness of the tumor, BRAF, RAS,HER2 or MSI status affect your decision?
Preferred options in NCCN guidelines: 5FU+cisplatin, 5FU+oxaliplatin, paclitaxel+carboplatin?
Would you consider using PARP Inhibitor in this situation?
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Is FOLFOX or 5FU acceptable without XRT if D2 resection?
For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...
Would you consider the addition of chemotherapy to proton beam therapy?
Patients oftentimes have cardiac co-morbidities with requirement for anti-coagulation making TKIs, including Bevacizumab, difficult to dose. Would the...
When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...
If so, which patients are the best candidates?
Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...
Would you continue to trend ctDNA to detect early recurrence?
Upfront surgery vs neoadjuvant therapy? And if neoadjuvant therapy, which regimen?
Patient has a good PS.
Quite often we encounter cholestatic hyperbilirubinemia, wherein GI and IR do not believe ERCP with stents or PTC will alleviate jaundice. If the pati...
Does this also apply to somatic mutations?
Do you routinely test for this with a re-biopsy?
If so, are there particular patient/tumor characteristics that influence your decision?
Would you treat with typical small cell paradigms such as surgery followed by adjuvant platinum doublet +/- radiation vs definitive chemoradiation? Or...
Given that majority of benefit is derived from the capecitabine, would this be an acceptable option to decrease patient contact with the healthcare sy...
If so, how much systemic therapy would you give before considering surgery?
What factors other than the Khorana score influence your decision regarding prophylactic anticoagulation in these patients? If prescribing an agent, w...
Would presence of features considered high risk in stage II sway your interpretation of the IDEA trial?
Would you choose to use IO or BRAF directed therapy based on BEACON? Or would you continue to use cytotoxic chemotherapy?
With extensive use of NGS testing, it is commonplace to identify mutations that have no validated therapeutic intervention, but strong biologic signal...
Package insert indicates discontinuing bevacizumab in PE and there are no guidelines on re-challenging after acute clot is managed.
In your experience, what approach has been successful to bridge to surgery?
ex. age, surgical risk, and/or performance status
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Up to six cycles of treatment were given in the ABC02 trial. Do you offer other treatments if you don't continue gem/cis beyond 24 weeks?
Do you have a similar approach in younger population?
CPS score of 40%. How and when do you incorporate immunotherapy into the treatment of metastatic gastric adenocarcinoma?
Of note, CLASSIC (Noh; Lancet Onc 2014) nor ARTIST (Lee; JCO 2012) evaluated other histologic subtypes, is the approach to treatment any different tha...
In light of the results of the ESPAC-4 trial, is combination gemcitabine plus capecitabine being considered over single agent gemcitabine for adjuvant...
If so, for what platelet count threshold and do you have a preference as to which agent?
In practice, does starting with chemoradiation followed by chemotherapy result in a significant delay in initiating chemotherapy or a patient's abilit...
If so, what agent(s) would you consider given the concurrent amplification and mutation?
Would the presence of peritoneal carcinomatosis change your treatment strategy? If Ki-67 <50%, would you avoid platinum based cytotoxics?
The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...
Given the variable and sometimes indolent disease course of these patients, as well as the absence of a clear overall survival benefit in the PROMID&n...
Does the pathology outweigh usual staging and risk factors?
What would be the next line of treatment, PRRT, capecitabine and temozolomide or other?
Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...
If you do employ this strategy, are there a number of liver lesions (eg <4) or duration of response that guide your decision making?
Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?
A number of phase 2 trials support various combinations (e.g. gem/ox, cape/cis, cape/ox, 5-FU based) -- how do you decide either between these regimen...
The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.
Do you utilize it immediately following chemoRT or wait until disease progression?
How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?
Would presence of TP53 mutation weigh in on the offer of radiation? Would there be any change expected on the chemo regimen?
Would you consider adding trastuzumab to cis/gem in the first line? If not, would you consider adding Her2 directed therapy to FOLFIRI or FOLFOX in th...
Provided the patient can have the solitary met treated definitively with SBRT and is otherwise a good surgical candidate
Do you continue with FOLFIRI for a period and then switch to olaparib (and if so, when do you make that switch) or do you switch directly after FOLFIR...
Does the precise location of duodenal cancer even matter given that treatment would be 5FU/platinum based. Also with the knowledge of impact of sidedn...
On occasion, patients with locally advanced gastric cancer are poor candidates for FLOT-like chemotherapy. Should such patients be taken to surgery up...
In a patient with a good performance status, would you consider this?
PDL1 is > 50%. There was no perforation or lymph node involvement.
I have seen anywhere from 4-6 months utilized. Is there any data to guide your strategy?
Has the utility of BRAF in CRC expanded beyond guiding prognosis? Is there a role in non-metastatic CRC?
Patient characteristics would unarguably be a deciding factor, but outside of these how would you approach the situation?
There is some data on TMZ and 5FU based regimens, but convincing evidence is lacking. How would you approach this situation?
I understand the perioperative trials are not based on tumor regression in cancer cells.
For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?
There is increased stroke risk after 65 years of age with bevacizumab. Does that stop you from using it?
KEYNOTE-062 showed deep durable responses are possible with upfront pembro, specifically in the CPS >10 subset, with OS advantage when compare...
For those that do receive adjuvant therapy with stage II disease, we know magnitude of benefit to be lower. If the decision is made to administe...
Do you offer perioperative chemo with metastectomy with an isolated liver metastasis? The RENAISSANCE/AIO-FLOT5 trial (PMID:30448343) is seeking to an...
How do you interpret results when IHC is < 1% but CPS > 1?
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
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...
When 5FU is a backbone to so many regimens, when (if ever) do you consider re-challenging so as not to abandon an entire line of therapy?
NCCN lists multiple preferred options.
Is there a role for SBRT with or without the addition of systemic therapy?
This is specifically in regards to metastatic colon cancer with good disease control of disease on FOLFOX and preserved hepatic function.
What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...
The patient had minimal to no response to neoadjuvant therapy.
What features would make you more likely to recommend radiation therapy with chemotherapy?
Does the presence of BRAF mutation affect your decision?
Do you test for COX-2 and PIK3CA mutations?
Would you offer chemotherapy alone per data from BILCAP or is there any role of radiation?
Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...
Does the Child Pugh score factor in your treatment decision, i.e. Child Pugh score C?
I have seen favorable clinical trial reports on dasatinib for metastatic disease, but no data on possible adjuvant use. NCCN guidelines suggest ...
For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...
Currently, nivolumab is approved as a second line systemic therapy for patients with metastatic HCC with Child-Pugh (CP) A-B7 based on results fr...
How do you approach a decision to retry a previously failed therapy if patient does not wish to pursue a clinical trial? Does sidedness (left or right...
Do you offer chemotherapy upfront in all patients or only if borderline resectable/unresectable? If you treat, what regimen do you use and how l...
What would you consider in the first and second line settings with intact MMR/MSI?
How would being MSI-H/dMMR influence your choice of adjuvant treatment?
Would you switch chemotherapy regimens (i.e if the patient received FOLFOX/Avastin, change to FOLFIRI/Avastin)? Would you treat wuth immunotherapy per...
Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?
does it matter whether it is given frontline vs later?
Does presence of intraperitoneal spread and solitary extraperitoneal visceral metastasis affect management?
Are these patients better candidates for preop chemotherapy alone?
Can you comment based on the results of PRODIGE 24 from ASCO 2018?
http://abstracts.asco.org/214/AbstView_214_218335.html
Would you use this combination in frontline vs later lines of therapy ?
Has the new data with the Natera assay from Reinert T et al in JAMA Oncology May 2019 changed your practice?
Do you start with 1250 mg/m2 BID and then dose reduce based on toxicities? Many studies across varied types of malignancies have shown good tolerabili...
If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...
Would you consider an aggressive approach such as hepatic resection if the patient is young and has good PS?
What adjuvant options would you consider? chemotherapy? radiation?
5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?
Would you consider chemotherapy either before or after the lung resection?
Would you consider referring the patient for HIPEC at some point in their treatment, possibly after giving adjuvant chemotherapy, especially if patien...
Is re-challenge with 5-FU safe? Do you consider Capecitabine?
What factors dictate choice of observation versus 6 months of adjuvant peri-operative chemoradiation plus chemotherapy especially if patient did not r...
Taking into account the overlap between treatment regimens for esophageal and gastric cancers, in what clinical context might you feel comfortable tre...
NCCN lists CRT as category 1 but also lists chemotherapy alone as an option. Is this decision based on discussion between surgeon and oncologist...
Specifically, rising levels noted while on somatostatin analogue.
If so, what regimen would you consider?
As in removing the 5-FU bolus from the start of therapy and not because of toxicity?
When will you prescribe 3 v. 6 months of FOLFOX or XELOX for the adjuvant treatment of colon cancer?
The abstract of the pooled meta-analysis is not definitive (JCO 35, 2017: suppl; abstr LBA1), and of the phase III trials (SCOT, TOSCA, Alliance/SWOG ...
If a patient with stage II or III colon adenocarcinoma who presents to your clinic 12-16 weeks after surgical resection do you give adjuvant chemother...
Does HER2 or PD1/PDL1 positivity change first line treatment (i.e. preferential enrollment on clinical trials) or do such patients still receiving sta...
The GTX (gemcitabine, docetaxel, capecitabine) regimen is listed as a category 2B recommendation in the NCCN guidelines- when would this be ...
Since immune check point inhibitors have been approved for GEJ and gastric cancer, would a distal esophogeal adenocarcinoma be considered GEJ or does ...
Would you consider subtotal gastrectomy vs medical therapy?
Most oncologists are comfortable offering FOLFOX for 1st line metastatic adenocarcinoma. Would you be comfortable offering FOLFOX to met. squamous eso...
Is there a change in approach over the past few years? Would there be a role for the 12-gene recurrence score?
NCCN puts "preferred" regimens but only category 1 is cisplatin and fluoropyrimidine. When would you use that regimen over FOLFOX?
For patients receiving adjuvant gemcitabine alone, would you now switch to adjuvant capecitabine alone?
In a patient who developed oligometastatic disease before completing adjuvant XELOX, what treatment(s) and duration of treatment would you recommend?
I have a few patients with kras braf mutation negative metastatic colon cancer treated with upfront FOLFOX- bev followed by 5FU-bev who had regression...
When PDL1 expression is negative, but IHC for mismatch repair expression is consistent with mismatch repair deficiency (MLH2, MSH2, and MSH6 expressed...
Stenting is not possible/not able to bring down the bilirubin level.
Regorafenib has been approved for patients with advanced HCC post-sorafenib, but the benefits are slight and toxicity substantial. Nivolumab has...
What about T3N0 disease? Would you use a recurrence score to help inform decisions?
Given recent FDA accelerated approval of pembrolizumab for MSI-H tumors regardless of site of origin, does it make sense to apply MSI testing, in...
If biopsy of the lesion is consistent with GI origin adenocarcinoma and there are no other sites of disease, would wedge resection followed by adjuvan...
Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?
Tumor involves stomach, liver, and lymph nodes. Pathology is suspicious for sarcomatoid carcinoma, possibly sarcomatoid cholangiocarcinoma.
In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...
The pathology shows both adenocarcinoma and neuroendocrine features.
If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?
How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?
Would you use 5-FU and radiation alone? Would your management be different for loco-regional (curative) vs metastatic situations?
If so, how would HIV/Hepatitis status affect you decision?
How do you weigh the recently presented/published data from the NETTER-1 and RADIANT-4 trials in your decision making?
Is salvage liver resection considered the next step in treatment for patients who may have resectable tumors after TACE? If so, do specific tumo...
Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724
Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...
In your practice, has tumor molecular profiling in pancreatic cancer led to the identification of any actionable targets for which a patient was put o...
Does the location of the pancreatic mass respective to the major vessels alter initial management (surgery, chemotherapy, radiation, or some com...
Do you have a preference for Regorafenib or Lonsurf or do you refer to clinical trials immediately given the known low response rates to these drugs?&...
Would you consider HER-2 directed therapy (lapatinib-trastuzumab)? Does being KRAS-mutated affect your decision?
Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...
Do you treat with standard of care therapy for microsatellite stable (MSS) colorectal cancers or pursue further work-up? Does this differ between adju...
Since some prior subset analyses have suggested that oxaliplatin may not improve outcomes of older patients with colon cancer in the adjuvant settin...
Does the recent Hopkins trial of pembrolizumab change your management of these patients?
If so, what is your preferred regimen?
Should oxaliplatin/capecitabine alone be the standard of care?
What are the targets (tumor bed, positive margin, nodes etc.)?
In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...
Is there a consensus on the MAGIC v. MacDonald debate?
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