Medical Oncology
Questions discussed in this category
Would you consider induction: TPF vs cis/gem or would you proceed with chemoradiation with cis/RT and consider adjuvant cis/5FU?
Do you recommend therapeutic phlebotomy to a certain Hct goal? Any strong evidence for thromboembolic risk related to erythrocytosis or if this is mit...
If so, would you recommend adjuvant chemotherapy and PCI after?
Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...
Does having a concurrent consumptive process e.g. DIC change your management?
Would you get bone marrow biopsy periodically? Would your approach change based off specific age or platelet count?
If confirmed neuroendocrine and PD-L1 pending, how would you treat?
Would you start with endocrine therapy + CDK 4/6 inhibitor or a chemotherapy based regimen?
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g. skin canc...
- Dialysis catheter used for hemodialysis- RIJ thrombus in dialysis catheter was incidentally found- Patient asymptomatic with no prior history of VTE...
Any special precautions needed?
Has the recent approval of atezolizumab/bevacizumab impacted your decision making?
Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.
Would you radiate? Surgery? Chemo? Follow with short interval scans?
How would size of adenopathy (e.g. <2cm vs larger) and time of recurrence (wi...
Are you routinely performing molecular sequencing? Would you modify your treatment approach in first or later lines based on PDL1 status?
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
Since desmoid tumors are associated with high estrogen states, is there an optimal contraception approach? Is there an optimal time for pregnancy? How...
When would you consider utilizing autologous SCT in those with a PR or SD?
Is there a potential role for BCMA-directed CAR-T or bispecific therapy in...
Such as dysgeusia, headache, rash, fatigue, etc
In this case, nivo/ipi discontinued for immune-related arthralgias requiring steroids and an anti-TNFa agent, now off all immunosuppression.
Recurrence picked up incidentally on CT. No germ line mutations, somatic tumor testing of node resulted negative.
PET confirmed isolated recurrence
Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...
The site of oligometastatic disease was to a supra-clavicular node and was biopsy proven.
Is single agent immunotherapy an option if CPS>10 if these patients cannot tolerate combination chemo and immunotherapy?
Is single agent paclitaxe...
Is there an age cutoff below which you would offer adjuvant chemotherapy regardless of Oncotype results?
(Example: A 35 y/o woman with T2N0, ER+, sen...
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...
IMPower110 data add further support to use of checkpoint monotherapy; however guidelines continue to support either I/O monotherapy vs chemo-immunothe...
Would you consider SBRT and continue osimertinib?
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 ...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
Patient was given ddAC + T
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...
The ALTA and ALEX trials showed better PFS with brigatinib v. crizotinib and alectinib v. crizotinib. How do you choose your first...
What other agents would have activity in a patient with NGS without actionable mutations?
Would you use ALK inhibitors such as crizotinib based on recent phase II data?
Are there any research efforts to combine ALK inhibitors with current ...
How do you distinguish this entity from other plasma cell disorders (eg. MGUS, MM, etc.)?
Review of literature suggests that most of these pa...
What clinicopathological features would need to be present for you to recommend adjuvant chemotherapy? Would you treat pT3 disease? Any specific histo...
Does post docetaxel PSA influence your decision?
Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...
Would you consider doing a pre-op RT prior to possible re-excision? If yes, what dose would you give? If the location is between L4-L5 spine.
Are there any subsets of patients that you're more inclined to offer maintenance?
In particular, for frail patients to avoid toxicity or for those that do not want chemotherapy
Bulky hepatic metastasis
What line would you give pembrolizumab?
Do you extrapolate from first line maintenance studies for duration of therapy?
What is the current data regarding acquired resistance mutations for ALK?
Should newer agents such as lorlatinib be reserved for later lines a...
For example, ALK+ in liquid platform, but negative on tissue biopsy.
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...
What would your treatment approach be- surgery or chemoRT? What is your preferred chemo regimen?
Is there a % threshold other than 100% (e.g. 95%) th...
Would you use a small cell regimen over a more traditional FOLFOX-esque approach?
Would you use trastuzumab/pertuzumab, trastuzumab followed by neratinib, or another strategy?
Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?
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?
What regimens would you consider combining it with?
Any specific combinations to avoid or special considerations?
Initial diagnosis was 15+ years ago
Would you choose to incorporate HER2-targeting agents, chemotherapy, endocrine therapy, or a mix of these?
Would you offer low dose or standard dose aspirin instead?
If so, do you allow a period of "washout" between immunotherapy and radiation?
Are there other regimens you employ for patients unsuitable for standard chemotherapy?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
The GeparSixto, CALGB 40603, and more recently Prospero support doing it; however, it is not currently endorsed by NCCN and the latter Prospero s...
At what lower end of recurrence risk do you offer adjuvant imatinib for patients with resected GIST?
What is your preferred risk stratification model?
There does not appear to be a consensus among experts as to what cutoff in recurrence risk ju...
If you recommend adjuvant chemo, please discuss which regimen.
How do you decide between supportive care v. chemoimmunotherapy? Is there a threshold of disease burden that would push you towards recommending hospi...
Assuming the patient is a candidate for all anticoagulation options (no mechanical valve, antiphospholipid syndrome, patient-specific contraindication...
Patient is <60 years old
Is Ommaya placement with CNS-directed therapy preferred to intrathecal or cranial irradiation? How do you interweave this therapy with systemic therap...
Excluding clinical trials
Assuming all other factors are favorable (pT1-2, TME, negative margins).
Aside from addressing the underlying case, is there a role for phlebotomy in secondary polycythemia such as in COPD or post-renal transplant erythrocy...
Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
Mets to spine and s/p RT
How would your plan differ if the patient could eventually receive mastectomy once co-morbidities improve?
While thrombophilia testing is not routinely recommended prior to starting OCPs, how about after the development of a VTE?
Masuda et al., NEJM 2017
Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?
Does your practice vary based on risk status (low vs high risk) or specific mutation status (BRCA+ vs HRD+) given PAOLA subset analyses?
As SCLC in never smokers is extremely rare, do you consider NGS testing, or do you modify treatment in any way?
Is there a threshold of when you would use chemo/radiation?
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...
Is it essential to wait one week after loading dose of erbitux to start RT for head and neck cancer?
In the post-op setting, would you delay 1 week even if it took them out of the 6 weeks post-op window? Meaning the loading dose of erbitux was given d...
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...
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 ...
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
What specific platforms for determining somatic BRCA and HRD status do you use for a patient who does not carry a germline BRCA mutation?
Assuming no actionable mutations?
There was an abstract in European J of Cancer (Srinivasan R, 2014:50: S6, P8) showing a good response rate with Bevacizumab and Erlotinib. Would you u...
Are MMR deficient tumors more resistant to cisplatin/carboplatin?
Current guidelines for breast cancer do not recommend periodic staging scans in absence of clinical indications.
Would you use R-CHOP or a more intensive chemotherapy regimen? Would you consolidate with radiation therapy after 3 cycles or use systemic thera...
While the CKD population is at high thrombotic and bleeding risk, would you consider anticoagulating a patient prophylactically if they had a history ...
Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?
What tumor or patient characteristics lead you to consider the use of neoadjuvant hormonal therapy without chemotherapy?
Would you recommend the patient stop testosterone upon this new diagnosis? If the patient is not amenable to stopping, would you incorporate an AI in ...
How do you decide on resumption or change of therapy?
Provoked or unprovoked VTE: Do you use D-Dimer (or even repeat imaging to reassess residual clot) in any capacity to guide anticoagulation duration? E...
In primary surgical resection, ENE on surgical path would be indication to add adjuvant chemoradiation. After progression through definitive chemoradi...
How would you approach chemoprevention if tamoxifen is
Are there particular patient characteristics (e.g. age, ER%, Ki67, grade) that make you more likely to choose neoadjuvant endocrine therapy?
Would a pCR to neoadjuvant chemotherapy change your management? (ER <5%, PR <5%)
If you do test, do you have a preferred testing method?
The patient was started on a beta blocker, as this is standard in the area.
Is the short time to recurrence a reason to not consider definitive management with surgery/radiation?
Should systemic therapy be added if pursuing d...
If so, do you avoid pegfilgrastim given that <12 days will lapse between its administration and the next cycle?
How does dialysis affect PSA lab values?
Based on available results from the IMMUNED trial, which evaluated the role of adjuvant nivolumab/ipilimumab or nivolumab monotherapy vs placebo in re...
Do features such as nodal involvement, Ki-67, degree of ER positivity, etc. change your management? Would you use any gene expression assays to help y...
Are there any data to support a specific TKI therapy for non-T90M exon 20 mutations/insertions?
Would you offer for T2N0 G3 resected disease with LVI?
Would you prefer TCHP over TCH? Would you consider adding an anthracycline?
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
If yes, what type of testing platform would you use?
Are there clinical factors which help stratify? Does your practice vary based on mutation status (BRCA+ vs HRD+?)
How do the 5 year results of SOLO-1 at ESMO 2020 impact your recommendations?
How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...
How would you approach additional systemic therapy? Would the clinical stage of the cancer affect your management?
Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...
Do you switch to alternative TKI? Dose reduce?
Post-auricular cutaneous angiosarcoma, pT1 (19 mm) with negative margins. Unclear if there is any indication for systemic therapy, given early stage a...
If no anthracycline, what alternative regimen would you consider?
Would you differentiate between patients with measurable disease vs NED? Are there specific data to guide us?
eg. 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...
Would you consider high-dose dexamethasone (deliberating adverse effects of antenatal steroids) or move to next-line therapies?
Would you favor 2nd line chemo (with or without trastuzumab) versus immunotherapy?
Patient has already received neo/adjuvant treatment with AC, paclitaxel, capecitabine, docetaxel, and carboplatin.
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?
If yes, do you re-biopsy for tissue, or perform blood-based sequencing?
Is MDS/AML risk increased with longer duration of therapy?
Is adjuvant radiation and/or adjuvant chemotherapy indicated?
The current NCCN guideline version 2.2021 is a little confusing. On page HODG-2, the clinical staging/risk classification did not include ESR, b...
Is there any safety data to proceed with TKIs/TDM-1 or to proceed as standard with THP?
For patients who remain NED for years, when would you feel it's appropriate to hold therapy?
Ref: EINSTEIN-CHOICE and AMPLIFY-EXT
Would you approach this differently in patients with inherited thrombophilias?
If advanced stage do you follow same guidelines as Scc? Do you use same Cth regimen? Role of total laryngectomy ?
How do you assess the risk of complications from including bevacizumab vs the known benefits of including it with chemotherapy?
Are there scenarios in which you would proceed with checkpoint inhibitor for PDL1+ disease before having full molecular testing results?
For patients who have progressed on first line checkpoint inhibitor (e.g. Nivo/Ipi) and second line TKI (e.g. Cabozantinib)
Would you try atezolizumab/bevacizumab or switch to a TKI?
What type of adjuvant chemotherapy would you offer?
Would clinically positive lymph nodes or residual disease at time of surgery change your decision...
Does your recommendation differ between autologous and allogeneic transplants?
Does your recommendation differ in allogeneic transplant recipients wh...
For example, in cold agglutinin disease or AIHA, antibodies can be detected via DAT, but are often not observed on assays for monoclonal gammopathies.
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?
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
What would you offer if the patient is not a candidate for cytotoxic therapy?
What systemic therapy options are available for ESRD patients?
Would you consider an Oncotype or Mammaprint? Would your management change if the patient had 1-3 positive LNs on SLNBx (as opposed to ALND)?
The woman was on on a GnRH agonist + AI due to her premenopausal status at diagnosis and now wants to know if she continues to need the GnRH agonist.&...
During the Stimate recall, how are we performing DDAVP challenges for newly diagnosed hemophilia A or von Willebrand disease?
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy?
Has data from the Lung ART trial presented at ESMO 2020 a...
Assuming no access to clinical trial
Would your decision for anthracycline change if the patient were elderly?
Would you add abiraterone or enzalutamide?
i.e. CA 19-9 >100
Are the rates of adjuvant chemotherapy used in ADAURA consistent with real-world practice?
What factors into your decision making and what systemic therapy would you offer?
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
What neoadjuvant or adjuvant therapy would you give?
When would you consider gemcitabine/abraxane as an alternative treatment?
Does your management change based on the type of end-organ involvement at the time of diagnosis?
Are there any reports of CNS involvement with non-se...
I know many centers are exercising extra precautions in light of the new concerns with coronavirus. How are people explaining things to their patients...
Have the RAPID or CALGB 5064 studies changed your treatment approach?
For example, gastric GIST, < 5 mitoses/hpf and size > 5 cm but < 10 cm is intermediate by NIH criteria but low by NCCN/CAP criteria. Th...
In low-risk patients (age < 40) or patients with very obvious causes of blood loss or iron deficiency (menorrhagia, pregnancy), do you routinely pe...
Are there effective therapy options that do not include steroids?
Would you send Oncotype during chemotherapy if not sent already? Would you stop adjuvant chemotherapy if a prior Oncotype was 25 or less?
When do you consider splenectomy? Is there a role for splenic radiation in non-surgical candidates?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
If post-op with clear margins would you prefer adjuvant RT or close observation with surgery for optimal reduction of local recurrence? This particula...
Patient has progressed through prior lines of endocrine therapy.
For patients with low risk, early stage, hormone receptor positive, HER2 negative breast cancer who initiated endocrine therapy in order to delay thei...
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
Would you consider using them in patients with CHEK2 mutations?
Patient has tolerated combination therapy well to date.
What is your specific therapy choice and duration?
Does the site of treatment factor into your decision?
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...
Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?
This includes handling saliva, vomit, sweat, vaginal secretions, semen, urine, and stool. Are there recommendations for intimacy, sex, laundry, and&nb...
I know that many advocate using vaginal estrogen in this situation. Most of the studies of vaginal estrogen in this situation have been small an...
Are there particular mutations (eg SF3B1) or syndromes (eg MDS/MPN overlaps such as MDS/MPN-RS-T) where you are more apt to using lenalidomide?
Would chemotherapy alone suffice? Repeat biopsy and EUS were negative for residual disease.
What if pathology showed NED?
Would you utilize radiation along with systemic therapy?
Would you consider gene profiling to determine need for chemotherapy?
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
In a patient who is not a surgical candidate, do you offer concurrent carbo/taxol rather than 5FU/oxaliplatin?
If so, what is your time threshold for when you'll start PCP prophylaxis--when you anticipate steroid courses greater than 1 week? 1 month? 3 months?&...
A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...
Knowing the differential effect seen with menopausal status in RxPONDER, would you avoid chemotherapy or still offer chemotherapy, given that only 15....
Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...
How would you balance the competing risks of these two diagnoses in her treatment?
Patient had a clinical T2N0 cancer at diagnosis, completed 6 cycles TCHP, and had 0.2mm residual disease with 80% cellularity, negative sentinel node.
Given recent approval of niraparib (Zejula) for the maintenance treatment of adult patients with advanced epithelial ovarian, fallopian tube, or prima...
Do you have any experience with intra-pericardial chemotherapy administration, and if so, in what cases?
Presented at ASH: FLIGHT trial
Patient is 34yo and G0 referred from surgical oncology. Laparoscopic specimens of myoma and what appeared to be adhesions were significant for maligna...
If patient meets high intermediate risk criteria, would you consider chemotherapy in addition to radiation?
An otherwise healthy patient with spleen only diffuse large B cell lymphoma with mild spleenomegaly, Spleenectomy plus Rchop or Rchop plus RT?
Does not technically meet high intermediate risk criteria.
Referring to a high risk patient with cT3N1 disease and ypT2N0 disease following neoadjuvant chemotherapy.
Any difference in recommendations if the patient was asymptomatic from her metastatic ER+ disease? (eg bone mets)
How do clinical risk and Mammaprint/Oncotype scores affect your decision?
> 7cm, grade 3. If chemotherapy offered, what is your preferred adjuvant therapy?
Does the degree of resectability affect your management?
If on pembrolizumab or nivolumab, when would you escalate to ipilimumab/nivolumab?
For example, will you recommend a certain vaccination timing in relationship to their treatment? Any concerns for reduced immune response or risks of ...
Or the converse: changing to IV formulation after starting on subcutaneous pertuzumab/trastuzumab?
Conversely, is there any situation where you would prefer the IV over the subcutaneous formulation?
ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.
For example, a patient on cytoreductive therapy and aspirin BID, but suffers an arterial event, or a patient who is already on therapeutic anticoagula...
What is the risk of perforation / fistulization?
Is there concern for impaired healing? Do you pause therapy and for how long?
Would you finish up pembrolizumab, give capecitabine, or both?
Patient underwent an axillary dissection with ITCs in 1/23 nodes.
Ex: TKI alone, TKI + checkpoint inhibitor, checkpoint inhibitor alone, TKI + mTOR inhibitor. Please specify drug regimen, if applicable.
Pathology is not carcinoid or small cell.
What if the patient is no longer responding to steroids?
This is in the setting of a patient who is now on ruxolitinib with rising leukocytosis and thrombocytosis, but cannot be on aspirin due to recent blee...
Would it change your decision if they had progressed on a first-line trial with cisplatin followed by pembrolizumab plus enfortumab vedotin maintenanc...
Is there a distinction between these tumors and patients with breast cancer with neuroendocrine features?
Given that trials excluded patients with low ER, PR for this approach.
What factors would determine your consideration of this as a recurrence versus a new primary and how would that influence your decision?
>10 cm, no metastatic disease identified on staging scans
No high risk features such as: lymphovascular invasion, perforation, or involved margins
What schedule do you use?
Does tumor size impact your recommendation? High grade? Young patient age?
Would it affect your decision whether original primary tumor and treatment was hormone positive or negative?
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?
In a patient with a medical or personal indication to induce oligomenorrhea/amenorrhea, how would you manage OCP therapy if a patient develops a VTE d...
Would gross ENE or R1 resection trigger you to consider adding chemo? If so, do you use weekly cisplatin or cisplatin/etoposide?
2 populations of cells with 95% negative by FISH (ratio 1.07) and 5% positive by FISH (ratio 10)
What is the lowest level you have seen with uncomplicated or complicated crises?
Do you consider placing an Ommaya for IT chemo with methotrexate or cytarabine? Knowing that leptomeningeal carcinomatosis carries such...
Can results from emerging AML data be extrapolated to high risk MDS populations?
Is there data to guide the choice of continuing the HMA in combinati...
i.e. EGD surveillance for varices?
Based on MINDACT update from 2020, a 5% difference in DMFS for patients 50 years or younger was noted, favoring treatment with chemotherapy (93.6%; 95...
Relapsed disease occurred 3.5 years after initial treatment
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
What clinical scenario(s) do you find results to be the most beneficial?
Is there a role for neoadjuvant cisplatin-based chemotherapy?
Do patients with sarcomatoid histology respond to checkpoint inhibitors?
Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?
What parameters do you use to decide to treat beyond progression? Is there any efficacy data from this specific study subgroup in IMbrave150?
Do you go straight to TMPRSS2 genetic testing or what other lab testing (e.g. hepcidin) could be helpful?
What considerations do you take for post-lumpectomy radiation and endocrine therapy?
The trial included only a small percentage of these patients.
Does lymph node positivity change your management?
ex. VEGFR2 expression, inflammatory signature, PDL1, etc.
Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.
Would you consider ALND and /or XRT to axilla?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
How do you sequence systemic therapy with radiation and surgery?
For e.g. how many cycles of ifos/doxorubicin do you administer in this context?
Bulky adenopathy compressed bilateral ureters, CrCl < 30, post stent placement, but renal function has plateaued
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
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...
Patient with ECOG 0-1
Would you consider adjuvant chemotherapy?
Nearly 11 cm in size
Does the recent CROWN trial affect your first line treatment decision?
Options:
1) ddAC-T- surgery- adjuvant capecitabine if residual disease
2) weekly taxol/carbo x 12 followed by dd AC x 4
3) Keynote 522- pembro/taxo...
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
Do you prescribe creams (e.g., urea) to prevent HFS, or is their use generally more reactive?
Are there any studies that compare them?
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy.
If there are a low-risk patients who can be monitored, how would you do so?
If unprovoked, would you consider stopping anticoagulation?
NCCN recommends either ISRT with rituximab/chemotherapy or ISRT alone in this scenario. What factors help your decision making?
How would your treatment change given pCR rates are reportedly much lower in triple positive patients?
Do you screen even asymptomatic patients?
In addition to TSH suppression, would you opt for RAI, targeted treatment based off NGS, or lenvatinib?
Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?
No primary thoracic mass identified. Knowing these often following an aggressive clinical course, would you consider concurrent chemo/RT, incorporate ...
Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy.
No actionable mutation on NGS testing. What approved therapy do you prefer? Are there specific investigational agents currently in clinical trial...
Many patients have had prior chemotherapy exposure with newly diagnosed AML that may not have classic therapy-related cytogenetics. How do you a...
Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?
Any role of neoadjuvant chemotherapy?
Would you use FOLFIRINOX as in Prodige 23 or FOLFOX as in RAPIDO?
Initial treatment with Taxane-Trastuzumab-Pertuzumab with then maintenance with the two anti-HER2 agents and and an aromatase inhibitor. Would you bio...
Given sacituzumab is an antibody drug conjugate of the active metabolite of irinotecan
Following chemoradiation, would you consider maintenance durvaluamb as for NSCLC even given the SCLC component?
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
Is there any data justifying the use of systemic therapy over localized therapy (e.g. radiation or surgery) in this situation prior to a progression e...
exam is + for ascites
The patient has a history of pelvic radiation and progressed through first line carboplatin/taxol. She has had a partial response to pembro/lenvatinib...
Especially if the patient had advanced N3 disease and is reluctant to pursue surgery?
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
If no testicular mass on exam or ultrasound - is there a role for orchiectomy? What chemotherapy regimen would you use and how many cycles?
Rituximab has entered the treatment algorithm in the first-line setting for the initial treatment of TTP. However, in remission, the role of adjuvant ...
How does histology, time to distant Mets affect your decision?
In patients with symptomatic disease that observation would not be appropriate, what is your preferred treatment?
Which Radiation modality, if any, would be preferred?
Typical chemotherapy does not work for SFT. In which circumstance would you use VEGF ( Temozolo...
Based on CheckMate 577?
Patient is on anti-hormonal agent (exemestane) with anti-HER 2 agents (trastuzumab and pertuzumab)
How does age play a role in this decision? If you do intensify therapy, how do you explain the negative results of CALGB/Alliance 50303?
If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.
Based on recent PAOLA-1
What if this was "triple-negative" antiphospholipid syndrome?
Does the specimen (blood vs tissue) used to detect mutation affect your consideration?
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?
For example, is there any data to suggest a benefit to starting with immunotherapy prior to TKI or the alternative?
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
Are you employing more or less primary chemoRT v. surgery for some cancers? Are you dose de-escalating? What are issues radiation oncologists should b...
What factors will steer you to use immunotherapy in this setting?
Are there particular populations in whom you would add an AR targeted agent after docetaxel?
Assuming patient received appropriate local therapy for brain metastases, which agent would you use?
Chemoradiation completed 1.5 years prior
She had already completed ddAC and two cycles of paclitaxel before the reaction.
Are there any chemotherapy regimens that can be used in elderly patients with poor PS who are not candidate for BEP?
HERO study - https://clinicaltrials.gov/ct2/show/NCT03085095
For example, if a post-menopausal elderly woman has a small focus of node positive disease, would once consider adjuvant abemacicliib + endocrine ther...
For example: do you use docetaxel + cyclophosphamide (TC) x4 and what is the evidence for using such a regimen
surgically confirmed node negative disease
Do you only give intrathecal chemotherapy or systemic therapy?
i.e. Cisplatin + Etoposide
Other than when there are obvious contraindications to anthracycline, such as cardiac dysfunction, when do you use a non-anthracycline containing regi...
Some considerations:
-Cabozantinib (Based on CABOSUN trial, NCCN does not list this as a Category 1 recommendation)-Nivolumab + Ipilimumab (CheckMate...
Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?
Is there any specific precautions or concerns to consider with TKI initiation if the patient has vasogenic edema?
Do you treat as you would a B-ALL? Does amount of nodal stations/disease matter?
What are the scenarios in which a rebiopsy is warranted for follicular lymphoma?
Would you modify the radiation dose or field in this setting?
Would you pre-emptively dose reduce chemotherapy, or modify the dosing of ruxolitinib?
I have heard <20% MRD. What about proceeding if patient is hypoplastic after chemotherapy?
Potentially, if metastasis responds, could be treated with surgery or radiotherapy
The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.
Both ARTIST and Inte...
Would you do systemic treatment or observe?
(assuming that the patient is int-poor risk, has measurable disease outside of the CNS, warrants treatment with appropriate PS)
Do you repeat the loading dose of trastuzumab?
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...
Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...
Would it matter the site of recurrence (ie lung nodule vs bone lesion)?
Patient had a solitary lung metastasis
Given that ADT + abiraterone and ADT + docetaxel have not been directly compared.
How has your practice been impacted by the ECOG 2108 (Khan et al. ASCO 2020 Abst LBA2)? Are there sites or distribution of disease that prompt you to ...
Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.
After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
BRCA status unknown currently
Is there data to support proceeding directly to cystectomy?
Does the absence of an OS benefit in the AG221-AML-005 presented at ASCO 2020 deter you from this strategy?
How do you decide on other chemo regimen? (Dosing, frequency, carboplatin based, non-platinum based etc.)
Would you use Cetuximab?
Altered fractiona...
What is the time window in which you would consider adding AR targeted therapy?
Is there a time frame in which you would NOT consider introducing sin...
Given the changing landscape of treatment, some patients may have already received capecitabine previously. Would this impact your treatment rec...
Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?
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
Would your answer change if the new lesion is ALH/ADH?
Presented with mass projecting into right/left anterior ethmoid complex
For example, a FANC mutation
Would you consider use of immunotherapy with checking PDL1? What chemotherapy agents would you consider along with mastectomy/radiation?
What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...
Would you obtain baseline PFT on all patients or only selected high risk patients? Would you repeat PFTs regularly or only if clinically symptomatic?&...
The patient remains without evidence of systemic disease outside of the CNS on serial imaging. Would you continue treating with SRS as lesions appear,...
Interest in approach for elderly population especially
Does residual grade 1-2 neuropathy from Taxol/ carbo 10 years ago affect your recommendation?
CT scans show omental and pelvic disease.
Would you consider an anthracycline based substitution vs changing to nab-paclitaxel or a combination with platinum agent?
Would you choose a platinum based agent? Other chemotherapy combinations?
Chemotherapy - Carbo/Gem (2nd line). PDL1 and BRCA negative.
In patients who are intolerant to hydroxyurea, anagrelide and interferon
Would you consider “bridging” therapy with something like an HMA?
No known cardiac risk factors
Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...
Would you recommend additional cytotoxic chemotherapy and/or switch her anti-Her therapy to T-DM1?
Would age influence your decision?
Data suggest patients with D842V-mutated or KIT/PDGFRA WT GIST do not respond to imatinib, but NCCN guidelines does not take into consideration mutati...
Ie for patients who are inoperable due to comorbidities?
If so, what regimen would you use? Would a carboplatin-based regimen be acceptable or only cisplatin?
For instance, germ line MUTYH mutations.
Do you prefer surgery vs radiation?
For surgical patients, do you offer neoadjuvant chemotherapy? If so what regimen?
Is there an optimal strategy to minimize unnecesary steroid use?For example, pre-treatment dexamethasone or 3 day dexamethasone? Prednisone only conti...
How do you counsel regarding uterine sarcoma risk?
Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?
Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?
If so, for how long would you treat?
What timeframe would you suggest to stop breastfeeding? From affected breast or both breasts?
Especially if HER2 negative on pathological specimen
Do you give first line CDK 4/6 inhibitors with Tamoxifen or Aromatase Inhibitor (+/- GnRH analogue)?
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...
Are there specific considerations you/your tumor board take into account?
Asymptomatic brain progression despite CNS surgery and SRS x2 over the past 2 years.
For a patient with high risk disease and a severe enough reaction that additional taxane-based therapy is contraindicated, do you consider alternate c...
Progression was observed only in the breast and required palliative mastectomy (T4b TNBC)
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
Is there an advantage to early diagnosis and intervention versus observation until the nodules are amenable to percutaneous biopsy?
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.
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?
Patient completed adjuvant AC-T 8 months prior to recurrence. BRCA negative, foundation medicine NGS pending.
Would you consider this refractory disease and go on to salvage regimen and auto-SCT, or is there a role for definitive XRT to the site of residual di...
PD-L1 is low and she has residual neuropathy from neoadjuvant paclitaxel.
The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?
eg LVI/PNI, poorly differentiated? If so, what regimen and for how long?
How does the changing landscape of first-line treatment impact your decision making for second line therapy?
For example- do you have experience using a LHRH agonist along with tamoxifen?
Since no data exists or is pending, and the two disease processes are similar, should we consider PARP inhibition in this setting? This is assumi...
While the KATHERINE trial for HER2+ used path staging, CREATE-X for TNBC with capecitabine used the Japanese Breast Cancer Society response criteria. ...
>5cm. If so, what is your preferred regimen?
Does acute leukemia sub-type affect your decision?
NCCN gives category 2b recommendation for either ER+ or ER-, HER2+ tumors, from the Tolaney NEJM 2015 paper with trastuzumab/paclitaxel. However...
If neurologic symptoms are absent or controlled, does that affect your treatment decision?
How do you balance risk of chemo after surgery with risk of progression of disease while waiting for healing after surgery before starting chemo?
MRI? Endoscopy? Physical exam?
What are there most evidence-based options?
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
What is the added benefit of Chemo-RT vs RT alone?
N1mic - few isolated malignant cells in 1 axillary lymph node
Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.
Given the recent reclassification of gain(1q21) as a high risk cytogenetic abnormality, has this changed your practice in managing newly diagnosed pat...
Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?
In cases where patient received 6 cycles of THP and 1 year of HP
Patient received adjuvant chemotherapy and anti-Her2 therapy 3 years ago.
If yes, would you offer tamoxifen or ovarian suppression plus AI?
Do you offer adjuvant chemoimmunotherapy after IFRT for Stage I to II low grade follicular lymphoma?
TROG 99.03 showed nearly 20% improved PFS at 10 years with chemoimmunotherapy despite 31/75 patients assigned R-CVP vs 44/75 assigned CVP without ritu...
How would the sidedness of the tumor, BRAF, RAS,HER2 or MSI status affect your decision?
Is there evidence for daratumumab-based doublet regimens?
Would your choice differ based on the patient's transplant eligibility?
Received adjuvant HER2 directed therapy 3 years ago.
Preferred options in NCCN guidelines: 5FU+cisplatin, 5FU+oxaliplatin, paclitaxel+carboplatin?
How does your approach differ for patients with stage IIA versus IIB disease? Age?
< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.
What steroid-sparing strategies do you use?
For example, for joing replacement surgery? Do you hold the revlimid for certain about of time before and after?
Pleomorphic sarcoma
Would you consider still immunotherapy even if aggressive disease vs single agent chemotherapy?
For instance, patients with ATM mutations
If so, please describe your experience and dosing.
Does the SYSUCC-001 trial presented at ASCO 2020 change your practice?
https://meetinglibrary.asco.org/record/186872/abstract
How do you weigh the negative results from IMvigor 010 of adjuvant atezolizumab vs the results...
If the cancer was also HER2+, would that influence your decision?
If so, would you consider it with monotherapy only or also with combined checkpoint blockade?
I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...
This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...
Does your choice of agent differ, or are you more or less likely to offer maintenance than if the patient had multiple myeloma alone?
Is there a preference for obinutuzumab over rituximab in early relapsed DLBCL, or in primary refractory disease?
Would you consider using PARP Inhibitor in this situation?
An ASCO 2020 poster from the German Testicular Cancer Study Group found that 37% of CSIS seminoma and nonseminoma were miscatagorized resulting in ina...
If offering neoadjuvant chemotherapy, which regimen would you use?
Is there data to support every 3 week dosage v. weekly?
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
What dose of radiation, what type of chemo, and what indications?
Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...
Are there subsets of patients who will not benefit with addition of first line immunotherapy?
What advice do you give regarding dietary practices, feeding tubes / parenteral nutrition, and pharmacotherapy specifically for cachexia?
Would you hold treatment for patients who develop PE/DVT while on BRAF-directed therapy?
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...
This is not the standard of care in the USA.
Would you consider the addition of chemotherapy to proton beam therapy?
Would your approach change based on the type of reaction (eg. Stevens-Johnson syndrome vs DRESS)?
How would you address maintenance (if any) post-tra...
Patients oftentimes have cardiac co-morbidities with requirement for anti-coagulation making TKIs, including Bevacizumab, difficult to dose. Would the...
What is your preferred treatment?
Any strong considerations for infusional vs. bolus doxorubicin?
For instance, would you discontinue when there is resolution of adenopathy and normalization of counts? If so, do you overlap ibrutinib with other the...
Should treatment be based on current histology (rhabdomyosarcoma) or origin (germ cell)?
This has been a common practice in the community. Is there a benefit for certain patients?
(i.e. CRi)
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
What if the patient has a history of confirmed COVID-19 but has since recovered?
The NCCN recommends both regimens.
Discussion of treatment options for midline low-grade glioma causing life-altering symptoms in a pregnant patient to avoid teratogenicity.
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
Patient previously received neoadjuvant carboplatin, anthracycline and taxane regimen and is BRCA negative.
Can it be prevented? How do you evaluate patients? What non-pharmacologic or pharmacologic interventions do you use for treatment?
When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...
Would you treat with platinum-etoposide alone again, or would you add atezolizumab?
IMpower133
Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
Does the availability of first line checkpoint inhibitor therapy affect your treatment decision?
How would this change if the patient had metastatic HR+,HER2- breast cancer and now has symptomatic pancytopenia secondary to BM involvement after TCH...
Do different modalities of imaging (PET vs MRI vs CT) help you to distinguish one etiology versus the others? What about other clinical characteristic...
If so, which patients are the best candidates?
Patient has MSKCC high risk disease. Immunosuppression is with mycophenolate mofetil and tacrolimus.
She has received 4 cycles of AC with no clinical response and is now pending completion with Taxol.
Would you consider single agent IO such as Nivolumab, given data are not strong (Checkmate 459)?
Do you limit it to post-pubertal patients? Do you offer it only if they will proceed with bone marrow transplantation after CAR-T?
GI work up negative. NGS cancer type and isochromosome 12p ordered and pending. Pathology at RPLND was negative for cancer.
Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?
There are conflicting reports of increased incidence of bleomycin-induced lung toxicity with G-CSF.
Do you worry about the ability to collect stem cells (at the time of progression to MM) if someone with SMM has been on prolonged lenalidomide?
Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?
Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...
T1a - 2mm; N1 - 1 ipsilateral lymph node measured 6mm
Oncotype says too small to test and NGS says too few cancer cells to determine status.
Would you continue to trend ctDNA to detect early recurrence?
What chemotherapy regimen would you recommend?
Upfront surgery vs neoadjuvant therapy? And if neoadjuvant therapy, which regimen?
Patient has a good PS.
Brain metastases have undergone resection, SBRT and WBRT
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
Would you consider using recently approved agent for symptomatic / unresectable PN, Selumetinib prior to Systemic Chemotherapy in this setting?
A patient with stage 3 melanoma on adjuvant nivolumab needs radioactive iodine for papillary thyroid cancer.
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?
Due to the apparent thrombogenic risk of COVID-19, would you consider holding tamoxifen in patients who test positive?
Do you routinely test for this with a re-biopsy?
There are multiple regimens including IGEV and most recently reported results of BEGEV without preference on NCCN guidelines.
Does the anagrelide shortage play a role in your decision-making? Do you avoid anagrelide in general?
Risk of CNS relapse in a reported series is less than 5%.
How does gBRCA status impact your decision?
What are the risks of infection with COVID-19 if using immunotherapy?
If so, are there particular patient/tumor characteristics that influence your decision?
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?
Given the rarity of DLBCL with MYC/BCL2/BCL6 rearrangements, do you approach this disease differently than DLBCL with MYC/BCL2 or BCL6 rearrangement, ...
Would your choice vary based on the patient's gender?
Aside from smoking cessation, what interventions have you found useful to manage patients with chronic symptomatic laryngeal edema? Steroids seem to b...
How are you modifying your current sarcoma-directed therapy in the setting of the COVID-19 pandemic?
For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?
Would you treat with typical small cell paradigms such as surgery followed by adjuvant platinum doublet +/- radiation vs definitive chemoradiation? Or...
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
Should staging and treatment decisions be made based on imaging alone?
Patient is a 67yo with a pT1 (2.5mm) pN1a merkel cell of the chest, 1 mm deep, widely clear margins, SLN with 1.5mm met, 11 additional axillary ...
Acknowledging that there is no time for good trials yet in this setting
Would the recommendation differ based on HR+ vs. TNBC vs HER2+ classification?
Would you recommend against immediate breast reconstruction?
Given that majority of benefit is derived from the capecitabine, would this be an acceptable option to decrease patient contact with the healthcare sy...
Would you consider delaying chemotherapy and proceeding only with endocrine for now?
Would you consider regorafenib based on the REGOBONE trial? Or would you consider other agents knowing that we do not have positive survival data with...
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...
Initially treated with anastrozole, current treatment is with fulvestrant.
Or do you consider addition of this agent in the re-induction setting for refractory disease?
If so, how much systemic therapy would you give before considering surgery?
Personally, my practice is to guide patients directly to surgery or to do neoadjuvant chemotherapy rather than to do neoadjuvant endocrine therapy, bu...
For example, if you had a triple positive breast cancer found on breast biopsy and repeat ER/PR/HER2 testing at the time of surgical resection showed ...
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?
The phase 2 trial of pembrolizumab in JCO 2019 showed efficacy, and I have patients preferring to avoid chemotherapy.
Would your practice vary based on hormone receptor or Her2 status?
What features are used to distinguish anaplastic multiple myeloma (AMM), and what other conditions should be considered in a differential diagnosis (e...
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
Mitigating the spread of COVID-19 is of utmost priority now that containment measures have failed. Social distancing will help "flatten the curve" of ...
Would you incorporate platinum into your treatment or enroll in an adjuvant IO trial?
No adjuvant treatment was given upfront
No primary identified in the contralateral breast. No distant metastasis identified.
Do you send multiple Oncotype testing for each sample in a multifocal or multicentric breast cancer?
Tumor size and grade meet criteria for oncotype testing in all foci.
Would you forego neoadjuvant chemotherapy?
Are you using growth factor support differently?
Any changes to immunotherapy?
Other considerations?
What factors other than the Khorana score influence your decision regarding prophylactic anticoagulation in these patients? If prescribing an agent, w...
IHC: ER 70%; PR 70%
OncotypeDx: ER - Negative; PR - Positive
Patient received anthracycline and paclitaxel for HR+ breast cancer in the past.
Would you monitor or directly offer systemic therapy?
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?
Do you proceed with Paclitaxel or go to surgery instead?
Is there specific workup you perform? Are there preventive measures? Once established, are there non-pharmacological and pharmacological treatments yo...
Would you even consider trabectedin in this case given its cardiotoxicity?
Would presence of features considered high risk in stage II sway your interpretation of the IDEA trial?
Is this also a marker of TKI sensitivity?
ie, not a classic NTRK3-ETV6 fusion.The patient has progressed through CDk4/6 inhibitors and intolerant of alpelisib, and does not want chemotherapy.&...
She has no other site of disease progression and has been on an aromatase inhibitor (progressed in the CNS while on a study with adjuvant abemaciclib)...
Would you proceed with maintenance atezolizumab or switch to second line therapy?
Would you choose to use IO or BRAF directed therapy based on BEACON? Or would you continue to use cytotoxic chemotherapy?
The APT trial reported excellent DFS, OS and RFI for tumors <=3cm but few were smaller T2s (2-3 cm) and few were >70 years old.
Is there data for weekly versus every 3 week cisplatin in this setting?
Residual disease with bulky retroperitoneal masses also present on scans
Stage T1bN1mic
Would you offer adjuvant TKI to patients with locally recurrent multifocal adenoid cystic carcinoma?
For example, for a patient that has been through multiple disfiguring surgeries and radiation and wants to delay time to next resection.
For instance, in a patient with isolated distant nodal involvement who had the lymph node resected but did not have a lymph node dissection?
Tumor 13 cm on back with retiform and kaposiform features; all margins negative except one abuts inked margin; atypical cells with 4 mitosis/HPF.
Add...
With extensive use of NGS testing, it is commonplace to identify mutations that have no validated therapeutic intervention, but strong biologic signal...
Assuming the patient is not a candidate for SRS
Would you offer nodal dissection and/or additional adjuvant immunotherapy in addition to wide local excision?
Package insert indicates discontinuing bevacizumab in PE and there are no guidelines on re-challenging after acute clot is managed.
Do you proceed to resection or palliative chemotherapy?
Assuming patient is not a surgical candidate and wishes to pursue definitive radiotherapy, what duration of ADT would you give?
This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.
Pre-treatment estradiol: <5
Estradiol after 1 yr: 35
How do you sequence systemic treatment options for metastatic HCC in Patients with Child's Pugh B Cirrhosis?
When do you incorporate immunother...
Do you ever consider stopping if stable disease and good tolerance?
Patient does not want chemo but is tolerating these well otherwise.
For example, if a patient had testosterone pellets injected, perhaps making endocrine therapy less efficacious, would that sway you to use chemo?
Being that this is a favorable histology would you use Oncotype Dx to help decide on neoadjuvant chemotherapy? Would you recommend neoadjuvant endocri...
https://www.ncbi.nlm.nih.gov/pubmed/31838010
Is dental evaluation indicated for edentulous patients?
Do you start with TKIs or platinums?
Do the potential late effects offset any benefit of mediastinal XRT in a young patient with bulky disease?
In the absence of side effects, would you be inclined to continue beyond 10 years as chemoprevention? Would you factor an intermediate/high oncotype R...
Any adjustments in terms of elective nodal coverage?
Would you treat this differently than someone who only presents with axillary nodal disease?
How would you manage symptoms? How would you adjust the adjuvant regimen (dose reduce, omit paclitaxel etc)? What strategies would you consider for pr...
This is a patient with a 1.8cm node negative HER2 positive tumor that is grade 3, high Ki67, and ER positive.
In your experience, what approach has been successful to bridge to surgery?
To me, the recent NEJM study is flawed in that the control arm did not have maintenance treatment while the experimental arm used maintenance Dar...
Would you recommend surgical resection if feasible? Or just monitor every 3-6 months as NCCN guidelines suggest?
Would your management differ based o...
How would a much higher risk cancer affect decision making? How would you treat him?
Does timing of recurrence (early vs late) factor into your decision and would you consider consolidation durvalumab?
Data presented at the 2017 SABCS (abstract GS1-01) of the EBCTCG meta-analysis stating a benefit of dose-dense chemotherapy applies to ER positive and...
Germline genetic testing negative
Would you proceed to autologous transplant, or switch to an alternate regimen (eg. daratumumab-based) first?
Would the type or degree of organ involv...
How do you choose between single-agent or combination chemotherapy versus newer treatment strategies such as palbociclib?
Abstract 5014 at ASCO annual meeting 2019 showed superiority of PSMA-PET imaging over fluciclovine-PET imaging. Are you utilizing these speciali...
How, if any, do you utilize genomic testing to guide systemic therapy?
Would your choice be affected by which high risk features the patient has (eg. double- or triple-hit status vs IPI score of 3-4)?
Keynote 407 recently published data on pembrolizumab +/- chemo for metastatic squamous cell lung cancer. The confidence interval for the group w...
Specifically with reference to rural settings where the logistics of early in the week delivery may be more challenging.
There is a national shortage of vincristine.
Does the degree of PD-L1 expression weigh into your decision?
If so, what is your approach to laboratory and clinical testing?
Are there clinical scenarios in which 5 years of tamoxifen alone remains sufficient?
In a patient with no evidence of bleeding, do you use a platelet cutoff? Do you utilize genomic testing (eg CALR, MPL, JAK2, etc.) to decide on cytore...
ex. age, surgical risk, and/or performance status
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...
Would you offer AI + OFS or tamoxifen to a woman with a grade 3 T2N0 tumor and OncoType of 15?
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
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?
Are there any special considerations with the PNET?
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...
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 ...
This question has come up most frequently with respect to the flu vaccine recently. Also, frequently this has been asked about the shingles vaccine an...
In light of the results of the ESPAC-4 trial, is combination gemcitabine plus capecitabine being considered over single agent gemcitabine for adjuvant...
Additionally, would the finding of any mutations, such as ESR1, change your recommendation?
For example, if a biopsy reads: lesion comprised of spindle cells arranged in a fascicular pattern, elongated, hyperchromatic nuclei, focally positive...
Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...
History of Multiple Myeloma with renal failure currently on velcade.
For example, is this still your approach in women with small tumors or node negative disease?
Example: Low grade mucinous tumor post bilateral mastectomy
e.g., subungual hemorrhage and onycholysis?
If so, for what platelet count threshold and do you have a preference as to which agent?
Once a tissue biopsy has confirmed light chain amyloid, what additional tests do you perform as part of a standard workup?
In whom should treatment b...
2D Echo - Normal Ejection Fraction
Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...
Would you offer adjuvant chemotherapy to a post-menopausal woman with a BRCA2 mutation and a T2N0 ER positive breast cancer with an oncotype of 12?
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...
There are multiple options that carry a category 2B recommendation in the NCCN guidelines. Does germinal B center type vs activated B-cell type play a...
How would you decide on VRd vs DRd for initial management of transplant ineligible multiple myeloma?
Are there specific patient groups where you would choose one over the other?
Are the cost differences significant enough to dissuade you from choosin...
In practice, does starting with chemoradiation followed by chemotherapy result in a significant delay in initiating chemotherapy or a patient's abilit...
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 ...
If so, what agent(s) would you consider given the concurrent amplification and mutation?
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 the SPARTAN trial, median PSA at study entry was ~ 7. Does the MFS benefit extend to patients with low PSA(< 2 or < 1)?
Do these events mandate discontinuation of lenalidomide therapy or switching to a different agent? Can appropriate therapy for these skin cancers be r...
Especially in light of the new Guardant data presented at AACR 2019
It is included in favorable histologies on NCCN, but no mention of how to treat based off HER2 status.
Does the extent of the surgery matter?
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 your recommendations change in the neoadjuvant versus adjuvant or metastatic setting?
Would you consider single agent immunotherapy given recent exposure to platinum agent or chemoimmunotherapy?
(ie Deuvelle criteria 1-3) Is it appropriate to discontinue brentuximab like you would with bleomycin?
In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?
Would the presence of peritoneal carcinomatosis change your treatment strategy? If Ki-67 <50%, would you avoid platinum based cytotoxics?
Patient only had upfront surgery.
Are the other options of chemotherapy that can be used instead of platinum based doublets, including with paclitaxel?
i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...
Specifically, do you consider repeating maintenance therapy after second line therapy if a patient had already received 2 years of maintenance rituxim...
If a young and otherwise healthy patient with normal echocardiogram and no other cardiac risk factors needs treatment for DLBCL, but has previously re...
She had disease progression on palbociclib and letrozole. She also has a PIK3CA mutation however did not tolerate alpelisib due to Grade 3 hyperglycem...
How would you specifically treat a grade 1, but HER2 positive lobular?
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...
Would you consider first line treatment with somatostatin analog or Lu 177 dotatate? Is observation an option for asymptomatic patients?
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...
-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX.
-Given that this is standa...
Would you still proceed to high-dose therapy and autologous SCT?
Would you incorporate radiation pre- or post- transplant? Or offer additional salvag...
Are there any data regarding response to checkpoint inhibitors for these patients?
If the patient has not experienced significant infectious complications? If so, what agent?
Patient has grade 3, pT3N0 disease and is s/p lumpectomy.
Do you re-challenge with nivolumab alone, change from nivo 1/ipi 3 to nivo 3/ipi 1 upon re-challenge, or stop immunotherapy altogether if grade 3?&nbs...
For instance, does isolated CALR mutated MF change your management?
For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...
PDL1 status pending; BRCA wild type
Specifically, do you utilize 3 cycles of chemo with ISRT or 6 cycles? Do you use R-EPOCH or R-CHOP in these cases?
Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...
For instance, do you ever start with dasatinib 50 mg daily? Are there any titration schedules that you follow?
Would you approach with curative intent with locoregional treatment or systemic treatment alone?
NCCN include active surveillance as an option in specific circumstances based on Rini et al. (Lancet Oncology 2016) however this set is not well defin...
Does the pathology outweigh usual staging and risk factors?
Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?
...
Any role to switch to MVAC?
Would you treat with chemoimmunotherapy based on IMvigor130 data presented at ESMO Congress 2019?
What would be the next line of treatment, PRRT, capecitabine and temozolomide or other?
Does the results of the tnAcity trial influence your decision in choosing a 1st line option?
In patients who continue to have insomnia despite diphenhydramine, benzos, and trazodone, are there other evidence based treatments that are helpful?
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...
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 suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
Status post nasolacrimal stent with improvement. Would you re-challenge or permanently discontinue docetaxel?
e.g. lymph node metastasis, presence of tumor involving the peritoneal surfaces and/or the abdominal wall. If so, which regimen would you offer?
NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?
Given the PFS benefit seen in the most recent ECOG-ACRIN, and the prior study of Rd showing an OS benefit, is your practice to put any high-risk SMM p...
e.g. mixed indolent/aggressive NHL, mixed NHL/HL? Is there a definitive way to discern composite from transformation? NCCN does not list recommendatio...
The NCCN guidelines regard MET exon 14 skip mutation as an emerging biomarker but no formal recommendation to start crizotinib. If high P...
Or would you conduct tissue or blood testing if no actionable results are found?
Is there any advantage of one regimen over the others?
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)?
Instead of FOLFOXIRI and bevacizumab as per TRIBE trial
A pilot study has shown activity of this combination in a small patient group.
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...
if so, are there specific cytogenetic, molecular, clinical, or hematologic factors that you take into consideration?
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...
How would you utilize PD-L1 expression to guide your decision making in this situation?
The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.
More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?
Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?
Have you changed your practice based off the FLYER trial presented at ASH 2018?
Prior localized HR+,HER2- breast cancer treated with adjuvant AC-T (5years ago)
Recent ipsilateral axillary recurrence (HR-,HER2+) s/p neoadjuvant TC...
Do you utilize it immediately following chemoRT or wait until disease progression?
How would you handle high risk features (eg double hit) with the limitations of dialysis?
Patient initially was started on cetuximab due to renal insufficiency of unclear chronicity (uncontrolled hypertension) that significantly improved du...
Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...
Would you treat until progression or for a defined "adjuvant" course after nephrectomy?
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 consider an aggressive approach with RT and/or surgery to the bone lesion and treat the primary as locally advanced breast cancer?
Do you use anti-hormonal therapy for these patients?
Role of neoadjuvant TC vs. anthracycline based regimen?
Although platinum/5-FU was used in KEYNOTE-048, can an alternative like carbo/paclitaxel be given since it may be better tolerated?
i.e. gross disease on scans that is too diffuse to be removed completely and/or decreasing but not normal markers
Do you pursue close surveillance, s...
Although not approved, for example, are you every using AVD-nivolumab?
Received neoadjuvant ddAC/T followed by adjuvant capecitabine for residual disease and found to have metastatic pulmonary nodules within months of sur...
Given not surgical candidate and within 1 year of chemoRT (recurrence within RT field), would you repeat chemoRT, RT alone, or systemic therapy alone?...
Would you continue osimertinib after radiation therapy, switch to crizotinib, or consider chemotherapy +/- immunotherapy?
Do you reduce the dose to <400 mg daily or employ dosing schedules?
What is your preferred neoadjuvant chemotherapy course for healthy adult patients with osteosarcoma?
Is there an age limit you use to consider MAP? Would you consider using AIM instead?
How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?
How would you approach a post-menopausal woman who now wishes to start adjuvant endocrine therapy more than 3 years since surgery?
Would you prefer first-line AI/CDK 4/6 inhibitor, or first-line AI followed by 2nd-line fulvestrant/CDK 4/6 inhibitor (either abemaciclib, once availa...
Would presence of TP53 mutation weigh in on the offer of radiation? Would there be any change expected on the chemo regimen?
SOLO1 trial studied stage 3/4 patients.
If finished adjuvantly, what would you do -- continue TC or change chemotherapy?
In this case, Gleason 5+5 in all cores, clinical T4.
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...
How about those with metastatic disease eager to maintain quality of life? Do you risk progression of disease if the TNF blocker is re-started?
Particularly if steroids are used for non-immunotherapy toxicities (COPD exacerbation, brain edema, autoimmune diseases to name a few) -- when do you ...
Specifically, would you consider utilizing sodium thiosulfate in adults based on the pediatric data from Brock et al. NEJM 2018?
Would you give 3 cycles of RCHOP followed by consolidative IFRT or 6 cycles of R-mini CHOP? Is there a role for 3 cycles of R-mini CHOP followed by IF...
Assuming the patient has an indication for treatment.
Thrombosis was ruled out and no etiology was found. Would you start ponatinib back at a lower dose, transition to omacetaxine or begin transplan...
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...
If yes, would you still recommend dual HER2 directed therapy?
After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...
How do you assess risk of tumor lysis syndrome, and is hydration sufficient or should hypouricemic agents be used as well?
Given the national shortage of etoposide starting in February 2018?
Rationale for adjuvant therapy was high Oncotype score.
What would be a safe dose for ifosfamide and how would you time with HD? Alternatively, would you recommend a different regimen? What about using neoa...
How do you treat if adriamycin is not an option?
Specifically concurrent ifosfamide? Induction AIM?
Given metastatic disease and not a trial candidate, how would you approach this scenario? How does an underlying diagnosis of NF1 affect your decision...
Given that DBA is associated with increased incidence of MDS, AML and other solid tumors, would this modify your treatment recommendations?
For early stage disease in a single breast, would you consider neoadjuvant chemotherapy or upfront surgical staging followed by adjuvant therapy? What...
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...
When, if ever, do you utilize adjuvant RT or chemotherapy?
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?
If so, what is your approach to sequencing and timing of targeted therapy and local therapy?
NCCN suggests either concurrent chemoRT or induction chemotherapy in these patients.
RP node with treatment related changes and surgical specimen from TAH/BSO no other foci of malignancy found.
PDL1 is > 50%. There was no perforation or lymph node involvement.
How long would you continue androgen deprivation after radiation?
How would you approach this situation in the absence of BRCA mutation data?
Her gynecologist wants her on hormone replacement therapy.
Should these patients be managed using small cell lung regimens?
I have seen anywhere from 4-6 months utilized. Is there any data to guide your strategy?
Do you tailor treatment to a goal response? Do you refer to data illustrating improved prognosis if the patient develops a CR or PR?
Does your approach differ by EBV status?
Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...
ie renal dysfunction, hearing loss, neuropathy
UpToDate indicates that VIP is an alternative to BEP for men who are not candidates for bleomycin, and that one criteria for not being such a candidat...
What if the patient has metastatic disease primarily in the CNS?
Has the utility of BRAF in CRC expanded beyond guiding prognosis? Is there a role in non-metastatic CRC?
Could carboplatin be considered here? Or any evidence for a PARP inhibitor?
Patient characteristics would unarguably be a deciding factor, but outside of these how would you approach the situation?
Liquid biopsy also showed AR amplification.
What are the targets (tumor bed, positive margin, nodes etc.)?
If so, after how many cycles of chemotherapy would you switch?
Patient has small cell carcinoma of the bladder with extensive hepatic metastases. Would you extrapolate the approach from IMpower133?
PIK3CA and ESR1 mutations on NGS without other targets and who has progressed on CDK 4/6 & AI and several single agent chemotherapies. Aside...
Does hormone receptor status impact your decision?
Would you recommend surgery, definitive chemoRT, or chemotherapy alone?
Exploratory analysis of the MAGIC trial suggested perioperative chemotherapy was detrimental in this subset of patients. Has availability of IO altere...
Retrospective data show very low response rate of immunotherapy in FGFR mutated patients.
NCCN suggests to consider continuation of imatinib from some single/multi institution non-randomized trials for ~2 years, but does not suggest what fa...
Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?
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?
There is some data on TMZ and 5FU based regimens, but convincing evidence is lacking. How would you approach this situation?
What would you use either in adjuvant setting or in metastatic setting?
Should cystectomy remain standard of care?
(Recently debated in JAMA Oncology:
http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...
Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.
In a patient with a prior response to ADT and progression on taxane and platinum chemotherapy, would you consider AR directed therapy?
Assuming there are no other indications at the moment.
I have seen some advocate for this in the community, although a Cochrane metanalysis did not find an advantage to giving the taxane earlier.
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
I understand the perioperative trials are not based on tumor regression in cancer cells.
In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...
Would you reserve TKI for after standard of care chemotherapy and immunotherapy or consider earlier line of treatment?
Would this affect your decision regardless of the stage and symptoms?
If so do you favor repeat tumor biopsy or cfDNA?
NCCN lists PCV as category 1 (and now with analysis in Abstract 2002 from ASCO 2019 showing benefit in IDH mutated), and temozolomide as 2B, yet temoz...
Would you forego anthracycline?
Do you await molecular and cytogenetic results prior to initiating therapy, or does age and function status primarily drive your choice?
NCCN does not list any preferences for the TKIs in their guidelines.
Aggressive histology with tall cell variant papillary thyroid carcinoma that's progressed 2 months after RAI and while on TSH suppression, without tra...
What if only site of progression was in the brain/CNS?
Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...
The ABC trials (Blum, JCO, 2017) used six cycles of TC. Is it because of the superiority seen with TC x four cycles versus standard AC x four cycles (...
I.e., Can day 2 Rituximab (RCHOP) or day 6 Rituximab (DA-EPOCH, Hyper CVAD) be given? Or should only Day 1 Rituximab be used with chemoimmunotherapy i...
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.
https://www.ncbi.nlm.nih.go...
Would you be more or less likely to use a cisplatin-containing regimen if a patient had previously responded to chemoradiation with concurrent cisplat...
Since some prior studies (eg. Eskelund et al. Blood 2017 130:1903-10.) have shown intensive chemoimmunotherapy does not overcome the ad...
Often patients are referred to medical oncology for adjuvant therapy for early stage breast cancer after BCS and just before starting radiation.
For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?
Since ECHELON-1 trial showed an improvement in PFS (but not OS), are there any situations where you would replace bleomycin with brentuximab...
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?
Do you see a role for adjuvant radiation therapy?
Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?
CT or PET? If so, how often?
Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...
These patients were excluded from the SOLAR-1 trial.
Tumor measured 3 mm.
There is increased stroke risk after 65 years of age with bevacizumab. Does that stop you from using it?
Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?
She developed biopsy proven skin nodules while on paclitaxel. PDL-1 positive and BRCA negative. Would you consider atezolizumab with a different agent...
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...
Mixed opinions about efficacy of IO therapy in this subtype.
KEYNOTE-062 showed deep durable responses are possible with upfront pembro, specifically in the CPS >10 subset, with OS advantage when compare...
ENZAMET and TITAN trials published at ASCO 2019 show benefit to both 2nd generation AR antagonists when compared to placebo but wondering how this wil...
What factors do you consider to aid in this decision making? The TIGER trial is a prospective randomized trial comparing these approaches.
She is otherwise asymptomatic and no LFT abnormalities. Would you switch to chemotherapy or offer different endocrine therapy?
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.
https://www.nejm.org/doi/full/10.1056/NEJMoa1813181
Is IO related pneumonitis in the radiation field or more diffuse?
For example - Would you offer tandem transplantation in a young, fit patient in a CR after first transplant, but with MRD detectable?
Some ENTs advocate for a neck dissection as a way to avoid chemotherapy if there is a high chance there is no ECE. This is without removing the primar...
Patient has hot flashes.
What clinical criteria would make you prefer TORS as the initial treatment approach?
Would you follow an algorithm such as the one proposed by Hall et al?
How do you decide between intrathecal chemotherapy vs systemic therapy with HD-...
Would you proceed with induction chemotherapy (eg TPF or cis/gem) to downstage or neoadjuvant chemoRT? Would your approach be different if there is or...
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...
Pathology is clear this is not a concurrent DLBCL and is indeed transformed CLL
Do you consider size > 2cm, visceral pleural invasion or vascular invasion as indications for cisplatin-based chemotherapy?
Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes? Do you utilize EBRT?
Are the early results of CASSIOPEIA (Abst 8003) from ASCO 2019 practice changing?
How do you decide? Do the results of recently published phase III data in the Lancet Oncology (Sun et al, Sept 2016) influence your decisio...
FDA package insert lists posaconazole as strong cyp3A4 inhibitor and states to consider other therapies.
http://abstracts.asco.org/239/AbstView_239_262655.html
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...
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 follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...
Is there any data as to whether TKI or immunotherapy is more effective in this population?
Do you offer perioperative chemo with metastectomy with an isolated liver metastasis? The RENAISSANCE/AIO-FLOT5 trial (PMID:30448343) is seeking to an...
If so, would you combine them vs monotherapy? Patient ECOG is 1
Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?
Is pembrolizumab considered standard of care in the 2nd line treatment of recurrent cervical cancer?
Does the phase II KN-158 provide sufficient evidence to change management?
Should this be done at the time of recurrence or after failure of 1st line therapy for recurrence?
If so, would you treat as node + BC with anthracycline and taxane regimen or non-anthracycline regimen (i.e docetaxel and cyc...
With increasing utility of immunotherapy across cancer types, patients with history of solid organ transplants may face need for cancer IO. How do you...
She developed isolated paraspinal recurrence that is not amenable for local therapies including RT.
Patient defers chemotherapy. She is currently on anastrozole/Herceptin and perjeta with a response but it is suboptimal. I would like to add a CDK 4/6...
Does the result of their salvage chemotherapy and whether PR or CR is acheived affect your decision?
The patient received THP and now is on maintenance HP when she developed CNS disease.
She had a ipsilateral chest wall recurrence after mastectomy ~5 wks after surgery that was known TNBC. Residual disease remained in known breast and a...
Initially stage 1 disease with high risk Mammaprint recurrence risk completed adjuvant chemo 15 months ago.
Does presenting total white blood cell count affect your decision? Does myeloid subtype affect your decision?
No actionable mutations were identified on next generation genomic sequencing.
How would you treat metastatic, unresectable, solitary fibrous tumor in a patient with mild hemophilia A? Each anti-VEGF medication comes with a warni...
Do you consider specific pre-medications, an alternate checkpoint inhibitor, or abandon ICI altogether?
If so, how would you modify this regimen?
Data was presented at ASCO in 2017 that abemaciclib has brain activity in HR positive breast cancer.
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?
She had not received any systemic therapy previously.
Most guidelines recommended adjuvant chemotherapy if tumor size was >3cm at the time of TAILOR Rx and patients with tumors >5cm were not include...
greatest measuring 1.0cm.
How do you interpret results when IHC is < 1% but CPS > 1?
Or would you proceed with standard-of-care adjuvant approach for high risk patients?
How might your decision change if the patient had a suitable 10/10 donor? How about if the patient had a targetable molecular mutation such as IDH2?
If neck dissection was done, do you offer adjuvant chemo and/or XRT?
The use of neoadjuvant CDK 4/6 inhibitors is not standard of care, but there are clinical trials looking at this question and patients who are chemoth...
AI+ CK4/6 inhibitor? Fulvestrant + CK4/6 inhibitor? AI + fulvestrant? AI + fulvestrant + CK4/6 inhibitor?
I.e. according to Mammaprint test?
Would it make a difference in terms of OS if the patient received AC?
Are there any patient and/or pathologic features that would lend you to considering IL-2 over other approved I/O or TKI therapies?
Would you proceed with modified radical mastectomy followed by systemic therapy, or would you consider neoadjuvant therapy? Would biomarker status mat...
Does the presence of N1 disease push you towards offering chemotherapy or would you continue endocrine therapy based on the PR?
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?
Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...
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?
In addition to gabapentin and Lyrica, what else can you do for chemotherapy induced neuropathy?
I have seen the question regarding treatment of non-clear cell RCC in general: https://www.themednet.org/question/3934. Is there any data or experienc...
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
Favored approach: AC-T +\- carboplatin, +\- gCSF
Is there one drug that carries the least risk of pneumonitis?
Do you use chemotherapy or radiation?
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...
The patient has been off her AI for two years.
How does grade or performance status affect your treatment decisions?
She has hepatorenal failure due to metastatic disease.
Is there a specific Ki67 percentage? P53-negativity?
Does anatomic location (eg retroperitoneal or thoracic) affect your treatment decision?
Do you have a time threshold for re-challenge with platinum? Of note, Checkmate 141 defined platinum refractory as relapse within 6 months of pl...
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?
Have you used anti-androgen therapy? Do you enroll patients on a trial or treat off label?
No viable cell was present.
Is there a role for attempting to continue EGFR inhibition in addition to chemotherapy for small cell lung cancer?
The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...
Would you use Lorlatinib , chemotherapy, immunotherapy or Chemo- immunonotherapy?
NCCN lists multiple preferred options.
What factors influence your decision?
Would you consider adding atezolizumab to a cisplatin/irinotecan regimen, or cisplatin instead of carboplatin?
Which patients should receive TDM-1, Trastuzumab+Pertuzumab or Trastuzumab alone?
In obese patients, would it make sense to switch from a GnRH agonist to an antagonist based on the data from the recent JCO study of dagrelix vs. trip...
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.
NCCN recommendations seem to mention these patients as not candidates for preoperative systemic therapy if the invasive carcinoma extension cannot be ...
Patient did not receive neoadjuvant therapy.
I have received inquiry from a patient's gastroenterologist regarding use of Entyvio or Stelara in such a situation.
What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...
For example, a patient has had multiple dose reductions for neutropenia and required an admission for infection while on palbociclib. Would you switch...
Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab
If it is still within the 12 month period and no disease recurrence?
Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?
Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...
If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?
The ABC trials show a DFS advantage of anthracycline-based regimens. Would age alone procure you from using it in a patient?
Any factors that would impact this decision (how far along adjuvant trastuzumab, disease characteristics, etc)?
The patient had minimal to no response to neoadjuvant therapy.
This patient is a young lady with stage IV ER/PR positive, Her2 negative with oligometastatic breast cancer undergoing a planned bilateral oophe...
Would you give adjuvant chemotherapy or start osimertinib?
The CALOR trial included patients that could receive HER2-targeted therapy.
Given the recent press release regarding the update on the phase 3 soft tissue sarcoma study of LARTRUVO (olaratumab) showing no benefit to the combin...
Given the recent results presented from the Griffin trial, would you choose a daratumumab-based regimen (eg. D-VRd) over other salvage options (V...
Only a small subset (22-24%) of patients in Katherine trial received a non-anthracycline containing regimen.
Can repeating Oncotype on a locoregional recurrence show a change in the biologic behavior of the cancer over time and guide treatment decisions?
In light of the data from ERA223 showing increased deaths and fractures with the combination of radium-223 and abiraterone compared to abiraterone alo...
The recurrence was 2 years after treatment with ddAC + T. If you elect for systemic therapy after local therapy, what chemotherapy would you use...
The patient completed AC-T three years prior.
Is there a subset of patients for which you consider one regimen over the other (i.e. AC-THP v.TCHP)? If using an anthracycline regimen, do you u...
IHC has been repeated and confirms triple negative disease.
What features would make you more likely to recommend radiation therapy with chemotherapy?
We know the longer we expose patients to lenalidomide, the harder collection will be. Would you collect now or switch to an alternative regimen to ach...
Does the presence of BRAF mutation affect your decision?
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.
What factors do you use to decide between weekly low-dose carboplatin and paclitaxel combination vs cisplatin based doublet, and do you routinelt...
Assuming there was an initial period of response to the mCRPC treatment.
Should this be the new standard of care based on the results from the recently published SOLO-1 trial?
Two new phase 2 studies this year with apatinib/oral etoposide (AEROC) and sorafenib/topotecan (TRIAS) were released, and NCCN also lists many single ...
Would you consider neo-adjuvant chemotherapy or treat with endocrine therapy?
One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone. How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...
What patient and disease factors may influence your decision?
Do your recommendations differ if patients are pre or postmenopausal given the data?
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
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 ever start radiation +/- 24-48 hrs from C1D1 for chemotherapy due to logistical barriers?
Do you prefer chemotherapy to start at beginning of ...
Do you routinely perform molecular testing?
Would you add atezolizumab to carboplatin + etoposide for small cell/neuroendocrine prostate cancer?
Treatment for small cell/neuroendocrine prostate is extrapolated from data on small cell lung cancer. It now appears that Carboplatin + Etoposide + At...
Would you offer immunotherapy combination (nivo/ipi) in patients who have failed nivolumab mono-therapy?
For instance, in stage III, would you use chemotherapy in neoadjuvant or adjuvant setting? What regimen would you use?
Do you recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?
Are you directed by symptoms, PSA changes or do you have a standard schedule regardless of those factors?
For example, in a patient > 70 years old?
Have the results from IMpassion130 changed the standard of care?
She otherwise does not have any BRCA mutations nor any underlying cardiac disease.
Late relapse, previously treated with BEP 30 years ago.
Would the site of disease relapse play a role in your decision (i.e. isolated lymph node recurrence versus failure at primary site of disease)?
Which appetite stimulants are the most effective? How do you respond to patients who request medical marijuana?
And how long? According to the ABCSG-16 Trial there was no difference in extending AI beyond 2 years after an initial 5 years.
Will you incorporate the results from KATHERINE into clinical practice now?
At what point (ie 8, 10, 12 weeks or more) would you no longer offer consolidation durvalumab?
Has the recent data presented at ASH affected your choice of regimen?
Would your choice differ between transplant-eligible and transplant-ineligible ...
The CREATE-X trial did not include HER-2 positive patients but the ER-negative population benefited from capecitabine. Would you consider capecitabine...
Shanafelt et al. recently presented results from the phase III E1912 study at ASH 2018. Will you still utilize FCR as first-line or now use Ritux...
Hormonal therapy would not be tamoxifen.
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 ...
Would you consider treatment based upon imaging alone or would you wait for tissue confirmation of metastatic disease?
Does the answer vary based on whether it is neo/adjuvant or metastatic setting?
How applicable is the SOFT/TEXT data in this setting ?
Would MRD assessments affect your clinical decision making for MM patients outside of a clinical trial?
Do you use etoposide-based regimens such as R-CEPP? How about substitution with liposomal doxorubicin?
Is concurrent chemotherapy necessary for these patients?
Analyses have showed questionable benefit with chemotherapy.
One example is the original breast cancer ER high 90%, PR mod to high 40%, Her2 negative. A liver metastasis diagnosed 2 years later showed ER l...
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...
NCCN guidelines suggest systemic therapy only or concurrent chemoradiotherapy. What is your approach?
For example first-line ribociclib/letrozole, and second-line palbociclib/fulvestrant? Without data, would there be any expected benefit?
The patient was previously treated with TAC x 6 (cumulative Adriamycin dose of 300 mg/m2) for a triple negative breast cancer. Would you consider inco...
Does your practice differ based on limited or extensive stage disease?
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 ...
Would you do a pertuzumab-based regimen or T-DM1?
Does papillary histology influence your decisions regarding surgery, chemo, radiation dose or nodal coverage?
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...
If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...
OS benefit was limited to patients with endocrine sensitivity, defined as either a documented clinical benefit (CR, PR, or SD for ≥24 weeks) f...
Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...
Routinely? Only with oropharyngeal cancer etc.? Given that low expression of EGFR subset did better, do you believe there is a true benefit in cetuxim...
The NCCN guidelines suggest surgery can be considered for up to T3N2 NSCLC after a period of induction chemotherapy/chemo-radiation without progressio...
Specifically, what regimen would you choose in a patient with new renal failure but not requiring dialysis?
Would you consider radiation and/or chemotherapy?
What is the ideal timing for monitoring and what laboratory tests should be used?
The published trials for adjuvant ipilimumab, nivolumab, pembrolizumab, and dabrafenib/trametinib excluded melanoma patients with stage 2 disease.
Initial pathology additionally yields low Ki-67 and is HER2 negative.
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?
What factors influence your decision (patient/disease characteristics, additional agents added to induction chemotherapy, CR1 or later, etc)?
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...
Does an age over 70 years, size, histology and hormone receptor status affect this decision?
If a patient obtains a PR or less to front line cladribine, what factors help you chose between a second course of cladribine, an alternative pur...
What other pathologic features may you use to guide therapy decisions (eg mitoses/grade or NGS)? If you decide on adjuvant therapy, what regimen...
Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?
The patient is relatively asymptomatic.
Patients with T3aN1a( stage IIIA per AJCC7) were excluded from nivolumab adjuvant trial. Would you consider nivolumab in these patients?
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...
Prospective International Randomized Phase II Study of Low-Dose Abiteraterone with Food versus Standard Dose Abiraterone In Castration-Resistant Prost...
The patient only had disease involving the right breast and axillary, cervical, and supraclavicular lymph nodes. She had complete response to with ddA...
Would you offer locoregional control alone, locoregional with adjuvant therapy, or active surveillance?
What would you consider in the first and second line settings with intact MMR/MSI?
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?
Is chemoradiation a viable strategy in osteosarcoma?
All tumors in this case were <2cm in size.
Or do you wait for platinum resistance?
Would starting with chemotherapy be preferred in this situation and consider concurrent radiation, then switch over to Pembrolizumab once some control...
Checkpoint inhibitors have demonstrated durable responses in clinical trials, which was never seen with cytotoxic chemotherapy in the past. What are t...
Essentially, is there any role for "COMET trial" type therapy for a low risk elderly patient?
Which neo-adjuvant or peri-operative chemotherapy regimen would you choose? NCCN guidelines recommend FLOT or FOLFOX in the peri-operative setting vs....
If so how would you select patients (ie. PS, histology, PD-L1 expression level)?
How about if disease is found in the CSF?
Is TC or CMF adequate or is only ddAC -> T recommended?
When is it warranted to utilize targeted therapies for known mutations (eg. midostaurin or an alternative TKI for FLT3 mutations, ivosidenib for ...
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
Does the choice of initial induction regimen affect your decision for when to employ lenalidomide maintenance?
Are there situations where you would c...
Are you routinely using letermovir as CMV prophylaxis in high-risk patients?
Any special considerations with its use versus other antiviral agents?
...
(HER2/CEP17 ratio <2.0, copy number >4.0 and <6.0 signals/cell)
As expected triple negative.
There is a gray area in clinical decision making where the practice seems to be different for borderline size tumors such as a 7 mm T1b lesion with no...
If yes, what dosage and do you use it continuously or intermittently? Regarding provera, many patients with ER/PR (+) breast cancer worry about taking...
In a patient s/p orchiectomy and with pelvic lymphadenopathy, would you consider lymph node biopsy to confirm involvement by non-seminomatous germ cel...
Would you consider switching regimens?
In light of the KATHERINE data- does this change your practice?
Do you test for pregnancy prior to each cycle?
Most of the studies have excluded non clear cell histologies. If you use a similar approach to clear cell, have you seen similar responses?
Should it be started at the initial diagnosis of bone mets?
For which patients would you consider addition of apalutamide or enzalutamide? How do you decide between the 2 drugs?
The recent SPARTAN trial showed a remarkable improvement in metastasis free survival and many other secondary endpoints except the lack of significant...
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?
How would being MSI-H/dMMR influence your choice of adjuvant treatment?
NCCN guidelines recommend both single agent Pembro and/or Ipi/Nivo as first line options. How would you choose between the two? In case of the latter,...
NCCN recommends to change therapy or maintain current therapy in this setting without further clarification. What thresholds would cause a change in t...
Not to decrease recurrence risk, but for chemoprevention of new ER-positive DCIS or invasive disease based on the Gail Model. If so, is there data to ...
Would you treat differently for de novo disease vs disease arising from large cell transformation of an indolent NHL?
Given the rarity of this in MF, is it still predictive of response to lenalidomide therapy?
For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...
Does their candidacy for autologous HSCT affect your decision to use maintenance lenalidomide?
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?
The FDA recently approved Braftovi (encorafenib) and Mektovi (binimetinib) in combination for unresectable or metastatic melanoma. When would they be ...
Is there any role for orchiectomy in this setting?
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...
How does the timing of recurrence play into your decision?
What are the special considerations in the non-metastatic setting vs metastatic setting?
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 ...
For example, would you consider this in a patient that would otherwise be eligible for adjuvant treatment (stage III or stage IV with oligometastatic ...
The patient is a pre-menopausal woman with low-grade, stage I IDC who initially could only tolerate 10 mg of tamoxifen for her first year of trea...
Young woman with Her2 positive disease involving her right breast, regional lymph nodes, and liver had a CR on PET after therapy with THP and now plan...
Would you offer adjuvant therapy post resection?
In the setting of the recent TailorRx data, would these patients be considered more high risk?
What is your treatment algorithm?
Would you switch chemotherapy regimens (i.e if the patient received FOLFOX/Avastin, change to FOLFIRI/Avastin)? Would you treat wuth immunotherapy per...
The NEJM 2015 paper by Tolaney et al only included 1.5% of patients with micrometastases.
Would your choice of treatment change if the same patient was T790M negative and osimertinib was given as a first-line therapy?
If a patient has ER/PR+ and Her2 positive disease in the primary tumor while axillary lymph node core biopsy is ER/PR+ Her-2 negative, do you man...
If so, what is the ideal imaging?
Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?
Is there a role for immunotherapy outside of trial setting?
Would this be any different for whole brain radiotherapy?
Pt is healthy and tolerating Tamoxifen well.
In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...
Which of the systemic options would you give concurrently with radiation therapy in the adjuvant setting? According to NCCN guidelines, high dose...
If a patient previously received taxane-based chemotherapy for ER/PR+ Her2 negative disease three years ago, is additional chemotherapy recommended at...
Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?
Can these patients be re-challenged with Herceptin?
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 ...
When would you sequence radiation?
Specifically, this patient had a new left lacrimal gland metastatic lesion that developed four years from her initial diagnosis and is currently under...
Would you change to an alternative triplet therapy, or switch to maintenance therapy?
Are there variations in depth of response short of CR that woul...
Testicular ultrasound, CT, and tumor markers are without abnormalities outside of the mass.
There are now five PD-1/PDL-1 inhibitors approved for metastatic bladder CA, one (Atezolizumab) as first-line therapy in cisplatin-ineligible patients...
does it matter whether it is given frontline vs later?
If there are 3 negative scans, do you continue annual screening?
Does the more recent data regarding the continued utility of brentuximab vedotin and the utility of PD-1 inhibitors factor in to your reasoning at all...
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...
Is there any data to suggest delayed initiation of adjuvant treatment would be beneficial? Or would close surveillance be reasonable? Patient is asymp...
Would you do this for ER+ patients?
According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...
Specifically, would carbo-taxol-bev-atezo (IMpower 150) be an attractive option given the activity of bev-atezo in sarcomatoid PDL1+ metastatic RCC (I...
Do you have experience administering these agents in the outpatient setting?
What systemic therapy do you use? Do you incorporate any multi-modality therapies?
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
Could one make a case for addition of Rituxinab frontline to increase the chances of a complete remission and even maybe achieve MRD-negative status ?
Does it differ from the treatment of other relapsed peripheral T-cell lymphomas?
Are there any clinical trials or case series focused on SPTCL?
Is t...
What factors if any would influence your decision and what would your approach be?
Does presence of intraperitoneal spread and solitary extraperitoneal visceral metastasis affect management?
Do we continue the hypomethylating agent indefinitely?
If yes, what factors push you to test for AR-V7 or would you test all patients in this clinical scenario?
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...
Would you give neoadjuvant chemotherapy in a patient with T1 N1 M0 ER/HER-2 positive cancer if they are candidates for upfront lumpectomy?
If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?
Is there any data for the benefit for systemic chemo in such situation?
Is there any evidence to use trastuzumab and pertuzumab without doxorubicin?
High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.
Is it reasonable to use single agent carboplatin for elderly patients?
Would you initiate abiraterone or enzalutamide for the rising PSA or wait until the patient is symptomatic or has a new site of metastasis?
For the Impower 150 trial, is there data reported on PFS and OS for ABCP vs ACP (atezolizumab/bevacizumab/carboplatin/paclitaxel vs atezolizumab/carbo...
Given the rarity of this diagnosis (5-7% of all AL amyloidosis cases), and the prognostic and clinical differences when compared to non IgM-AL am...
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...
Many times we encounter patients who do not have a tissue sample readily available or in whom obtaining such a sample would be hard. On a more molecul...
How do you interpret the results of Checkmate 227 in light of Keynote 189 and Keynote 407?
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
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
If so, after what duration?
Patient currently has bone and lung metastasis.
In the context of the new staging systems and possible differences of HPV mediated vs smoking mediated oropharynx SCC, would you ever not recommend co...
Does the recent FDA approval based on PFS and response rate in KEYNOTE-021 warrant it's use?
Technically, you can have up to 55% of larger cells circulating and still be called CLL.
Can you extrapolate the data on Durable Complete Response After Discontinuation of Pembrolizumab in Patients With Metastatic Melanoma to patients on a...
Would you use this combination in frontline vs later lines of therapy ?
The PERSEPHONE trial to be presented at ASCO suggests 6 months of Herceptin is non-inferior to 12 months in early Her2 postive disease.
Would you observe until progression or would you place the patient on maintenance?
Patient does not have BRAF mutation.
If so, how frequently?
With studies showing non inferiority to zoledronic acid q 3 months in support of bone metastatic disease, would you consider extrapolating this data a...
Has the new data with the Natera assay from Reinert T et al in JAMA Oncology May 2019 changed your practice?
In this study, doses of 2mg/kg Q3wks, 10mg/kg Q3wks and 10mg/kg Q2wks were used. What did the majority of these patients in CR receive?
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...
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...
Would you consider "aggressive" concurrent chemoradiation followed by SRS to the CNS lesion and possible consolidative immunotherpay (the PACIFIC...
How do you treat these patients if they progress after immune checkpoint inhibitors?
First episode was 10 years ago and patient did not receive XRT. Would you give XRT now?
Current NCCN guidelines seem to support a variety of approaches.
The patient is cisplatin ineligible due to renal dysfunction.
Would you consider MS an absolute contraindication to this treatment?
What is the optimal regimen for a pre-menopausal female with progression of ER+,PR+ and Her2 neu negative breast cancer while on tamoxifen for six mon...
Do you consider it only in lymph-node negative or up to three lymph nodes?
Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.
Pt previously treated with radical prostatectomy and adjuvant radiotherapy.
If recommending therapy, what is the role of concurrent abiraterone + AD...
Would your recommendation change at all depending on time to relapse or original stage of melanoma?
Given the results of Keynote 189, is there any benefit of chemotherapy+pembrolizumab in specific subsets of patients in the first line setting?
The patient initially had a great response to THP for four months, but now with quite a bit of lung, pleural, and nodal involvement.
If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...
Based on new FDA approval of nivolumab plus ipilimumab in the first-line setting for intermediate- and poor-risk disease, would you give the combinati...
Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?
Could observation and serial cystoscopy be a reasonable option or is surgery necessary? If recommending surgery, can a procedure less than a nephroure...
Intramammary lymph node involvement has been shown to have a poorer prognosis (Hogan, Surg Onc, 2010). Would Oncotype be useful in these patients...
Assuming that the involved area is too widespread for RT. Would you try single agent rituximab first? Or obinutuzumab? What if rituximab alone gave on...
Would you consider capecitabine in addition to paclitaxel?
CIC-DUX4 fusion sarcoma is a rare entity, the aggressiveness of which is comparable to Ewing's sarcoma. A major dilemma is whether to treat these pati...
Provided patient is tolerating treatment well.
Is there any data to support this?
No prior chemotherapy.
The recent NEJM phase II trial http://www.nejm.org/doi/full/10.1056/NEJMoa1715519?query=featured_home looked at a small cohort of 24 patients and show...
Knowing that the analysis now is more detailed than it was 10 years ago.
What about non-Ashkenazi Jewish breast cancer patients with suspic...
How do you choose between 3 and 4?
While we await the results of TailorX, what has been the experience in your practice? If the decision for adjuvant chemotherapy is made, do you f...
If staged so due to satellite lesion and negative nodes? How do you decide between adjuvant PD-1 inhibitor or BRAF/MEK inhibition in BRAF-mutated pati...
Assuming SRS to the resection cavity is advised, would you recommend early immunotherapy to improve outcomes/enhance a possible abscopal eff...
Do ER/PR and HER2 markers have any role?
Would you use oncotype to guide your decision?
In the absence of clinical trial, is there are role for dose-escalating alectinib, or would you consider brigatinib or chemotherapy?
Would you consider an aggressive approach such as hepatic resection if the patient is young and has good PS?
Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...
What adjuvant options would you consider? chemotherapy? radiation?
the MZL was untreated in the past prior to transformation.
Do these patients have a higher risk of recurrence post CR as opposed to patients with de ...
Is it commonly used if no clinical trials are available?
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
Originally received anthracycline and taxane based regimen.
Would you use carbo/paclitaxel or capecitabine or a different approach?
How do you get 17p testing on someone with only lymphadenopathy
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?
Specifically, in patients that had progression or developed toxicity on ibrutinib? Idelalisib is very toxic and venetoclax a labor-intensive drug to g...
Even though Venetoclax is not FDA-approved yet, assuming you can get it off label?
1. Gemtuzumab: What dose/schedule and which HMA?
2. Venetoclax: W...
Is there any data on safety of radiaiton with pertuzumab?
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
Biopsy of other sites is more consistent with carcinoid tumor.
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?
These patients have been largely excluded from these trials. What if the infection is well controlled?
In a patient who underwent laparoscopy for endometriosis and was found to have a 1mm focus of neuroendocrine tumor, would you recommend further surger...
Would you consider resection? Or maybe anti-CD20 monoclonal antibody?
My practice had always been to transfuse for plts < 10, but the recent ASCO guideline change suggests that in the post-autoSCT setting it is ...
NSABP B51 and B52 specifically prohibit this.
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...
In the absence of any other classic CLL indications for treatment.
Is there a difference among all the commercial genetic testing labs? Is there anything beyond CLIA- and CAP-certification that we should look for...
After mastectomy for the locally recurrent disease, would you consider "pseudo-adjuvant" chemotherapy for local recurrence per the CALOR trial? If so,...
What factors dictate choice of observation versus 6 months of adjuvant peri-operative chemoradiation plus chemotherapy especially if patient did not r...
Can you apply the ACOSOG Z0011 study to women who have HER2 positive disease?
The CALGB regimen is quite complicated.
Assuming it is clinically indicated, would a checkpoint inhibitor be efficacious in a patient who has a concurrent autoimmune illness (PMR/TA) and is ...
If filgrastim, how many days would you give? Pegfilgrastim is often not covered by payers if given less than 14 days before chemotherapy.
Would you ever considering re-starting immunotherapy before completing the taper?
According to the new guildelines on managing immunotherapy related ...
Do you refer all patients who are felt to be at high risk to a genetic counselor for testing or are you comfortable performing a MyRisk panel in your ...
The patient has no medical problems and no history of leukemia/MDS. Biopsy of the filum terminale and arachnoid confirmed a myeloid sarcoma and MRI sh...
Recent NEJM study showed an increased breast cancer relative risk in longer durations of hormonal contraceptive use that could last up to 5 years. Pre...
An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...
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 ...
http://www.nejm.org/doi/full/10.1056/NEJMoa1612645?rss=searchAndBrowse&#article_abstract
If so, how do you sequence it with adjuvant radiotherapy...
If so, what would be the regimen?
Pt has progressed on AI and Faslodex. Goal is radiation to axilla as a palliative intent and Capecitabine to control systemic disease.
Data reported by Motzer et al Lancet 2015 demonstrated a statistically superior PFS benefit of lenvatinib monotherapy over everolimus alone. In partic...
What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?
Subq has been shown to have lower risk of neuropathy. Is there any reason to use weekly IV still?