Medical Oncology

Thoracic Malignancies   

Questions discussed in this category



If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?

Does the availability of first line checkpoint inhibitor therapy affect your treatment decision? 

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 ...

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...

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?

The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?

Keynote 407 recently published data on pembrolizumab +/- chemo for metastatic squamous cell lung cancer.  The confidence interval for the group w...

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...

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 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 ...

In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...

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?

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...

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...

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...

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...

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?

In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial. https://www.ncbi.nlm.nih.go...

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? 

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.

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...

Do you consider size > 2cm, visceral pleural invasion or vascular invasion as indications for cisplatin-based chemotherapy? 

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...

Do you consider specific pre-medications, an alternate checkpoint inhibitor, or abandon ICI altogether? 

Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? 

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...

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?

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...

The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...

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...

Would you consider adding atezolizumab to a cisplatin/irinotecan regimen, or cisplatin instead of carboplatin?

No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.

What factors do you use to decide between weekly low-dose carboplatin and paclitaxel combination vs cisplatin based doublet, and do you routinelt...

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 recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?

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 ...

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...

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...

 Ex. TP53, BRCA, T790M, or another? As of now, T790M mutation is one of the few de novo mutations found in treatment naïve patients  th...

The ALTA and ALEX trials showed better PFS with brigatinib v. crizotinib and alectinib v. crizotinib. How do you choose your first...

Would starting with chemotherapy be preferred in this situation and consider concurrent radiation, then switch over to Pembrolizumab once some control...

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

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 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...

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...

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...

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

Are there any data to support a specific TKI therapy for non-T90M exon 20 mutations/insertions? 

If so, what fields do you irradiate? The initially involved nodal regions? If not, do you consolidate at any point in the future (ie after a loca...

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?

Do you increase dosage of the TKI or switch to a different generation TKI?  How does your answer differ for EGFR vs. ALK, and for discerete brain...

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 ...

What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

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...

If patients do recur, do you perform these tests on the initial surgical specimen or on tissue from a fresh biopsy (or both?)

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?

Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage? 

Nivolumab/ipilimumab is an option listed within NCCN guidelines for this patient population based on the early results of the Checkmate 032 trial. Do ...

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...

Should we be routinely sequencing ALK to select an ALK inhibitor with the appropriate efficacy, matched to resistance patterns?

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...

If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib. 

If PET/CT is unrevealing for a primary source, would you treat such a patient with platinum-etoposide or monitor closely until further disease progres...

Does recent data from the OAK study showing a survival benefit for atezolizumab over docetaxel even in non-smokers affect your decision making?  

If not what radiation fractionation regimen is preferred for otherwise good KPS patient? 

Since results of the phase III J-ALEX study were reported at ASCO 2016, do you try to obtain alectinib in the first-line setting instead of crizotinib...

Based on recently published data from CheckMate 032, do you now offer nivolumab to small cell patients who have progressed after first-line chemothera...

Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?

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...

It seems like the RADIANT trial, finding an 18 month DFS benefit for adjuvant erlotinib, would favor this, but the study calls this "not statistically...

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 surveillence 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...

Should mutations other then EGFR and ALK be routinely tested for? Should next generation sequencing be routinely done?

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...


Papers discussed in this category


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BMC Cancer, 2015-08-15

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International journal of radiation oncology, biology, physics, 2012-06-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2015-01

Lancet, 1998 Jul 25

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-03-10

Radiat Oncol, 2015 May 27

International journal of radiation oncology, biology, physics, 2016-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-04-01

The New England journal of medicine, 2016-11-10

The New England journal of medicine, 2018-01-11

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The New England journal of medicine, 2015-10-22

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Pulmonary medicine, 2012

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Clin. Cancer Res.,

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Lung Cancer,

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N. Engl. J. Med., 2017 Jun 04

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JAMA Oncol, 2019 Jul 11

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Eur. Respir. J., 2017 Jun 01

Clin. Cancer Res., 2018 Oct 08

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2019-02

Lancet, 2019 Oct 04

International journal of radiation oncology, biology, physics, 2018-03-15

J Thorac Oncol, 2019 Feb 16

Cancer discovery, 2017-04

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2016-08

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Cancer, 2017-11-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-08-20

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Cancer, 2011-11-01

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The New England journal of medicine, 2014-11-13

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Cancer discovery, 2015-08

The New England journal of medicine, 2012-11-01

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