Medical Oncology
Questions discussed in this category
Has anyone tried this approach with success?
OlympiA trial did not include her2+ breast cancer.
And if the tumor is MSI-H, does that alter your thoughts?
Do you choose Lorlatinib or brigatinib? Or do you try to add chemotherapy to alectinib?
Also is there value in using voxelotor for the purpose of reducing hemolysis, and if so what parameters do you use to determine when to initiate voxel...
If you do recommend resuming carfilzomib, what dose and frequency would you use?
If any clinical benefit (ie. CR, PR or SD) would you consider switch maintenance avelumab, surveillance until progression, or an alternate regimen?
Would you use it for initial staging or at time of biochemical recurrence?
Would you offer topotecan, lurbinectedin, or another agent given the CNS progression as well?
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
Molecular profiling revealed no targetable alterations, however tumor mutational burden was >10 mut/Mb.
Or with other available IO/TKI combinations should this be strictly reserved for intermediate/high risk patients only?
If selecting IO/TKI, do ...
What is your general rationale for selecting from available options?
Given seemingly improved efficacy in patients who had less prior treatment, would you consider use after only one prior agent rather than two? W...
Patient in mid-30s with no major medical history presented with isolated left neck swelling. Incisional biopsy w/ HTLV1/2 associated ATLL, Ki67 of >...
Largest invasive focus is 0.4mm
What about multiple anaplastic plasmacytoma without bone marrow involvement?
Do you select treatment based on toxicity profile since efficacy of regimens will likely never be directly compared?
Are there QOL indices that can ...
Do you try to keep Hb> 10 or 12? Or somewhere in between?
Or what is your preferred regimen for stage IV ccRCC following progression on IO/IO?
The patient previously received endocrine therapy alone and in combination with CDK 4/6 inhibitor. She does not have any targetable mutations on NGS. ...
Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...
What would be your radiation volumes/dose and choice of chemotherapy?
Or would you restrict such treatment to patients with known pathogenic germline BRCA mutations?
Given ductal histology, is docetaxel preferred over NHT?
Assume normal cardiac function and no obvious co-morbidities. No anthracycline previously due to age alone. The patient’s BRCA status is unknown...
This situation can feel uncomfortable. Would this feel safer if patient is s/p mastectomy and had TNBC?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
The FDA recently granted breakthrough designation of tastuzumab deruxtecan in the second line setting. Given the results of DESTINY-Breast03, what is ...
What steps should be taken when switching premenopausal women from tamoxifen to AI? In this case, the change is due to newly discovered endometrial th...
For example, does a higher recurrence score influence your choice of TC versus AC-T? Or your choice to add ovarian suppression to a premenopausa...
E.g. disease burden causing airway or vascular compression.
Ki-67 > 95%, PET-CT negative for any additional disease.
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy?
Are the results of the recently published negative phase ...
Are there other high or very high risk features that would also contribute to your decision making?
CNS recurrence occurred within two years of prior neoadjuvant therapy
If blood counts are sustained, do you continue or delay?
Does severity of dementia play a factor in recommending ADT?
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
In which situations would you consider this a reasonable treatment option?
NSABP B51 and B52 specifically prohibit this.
TNBC diagnosed in 2nd trimester. Neoadjuvant rx not given due to complicated pregnancy and went straight to surgery due to HR+ biopsy. Surgical pathol...
Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?
Would you offer adjuvant RT or chemotherapy? If so, what chemotherapy would you prefer?
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
Do you routinely recommend any dietary changes or is the evidence not convincing?
Are there other supportive care interventions that would otherwise be covered by hospice?
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
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...
Genes such as ATM, CHEK2, PALB2, RAD51C/D, BRIP1 seem to show some potential increased risk of ovarian cancer. Should these patients under prophylacti...
What about a higher penetrance PV such as PALB2?
See JCO OGR 8/2021 by @Mark E. Robson discussing management of non-BRCA pathogenic va...
Would you prioritize the head and neck cancer or treat the lung cancer first with SBRT to take care of it first? How about if there is mediastinal inv...
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
Would your decision be influenced by whether a pathologic complete response was attained?
Would you elect for concurrent chemoRT or RT alone?
Would you consider omitting treatment if small tumor and early stage? Or would you use tamoxifen?
In a scenario where patient's other clinical/familial risk does not sufficiently qualify them?
See JCO OGR 8/2021 by @Mark E. Robson discussing manag...
If so, what would you consider ordering?
The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...
Have you used anticoagulants other than coumadin? Or is that the only appropriate agent given monitoring is based on PT/INR?
Do you worry about fluoropyrimidine resistance with concurrent chemoRT? Is there any role for neoadjuvant immunotherapy?
Specifically do we know by how much each intervention reduces the risk of developing MBC or increase breast cancer specific as well as overall surviva...
The patient is treatment naïve and asymptomatic. She also has disease in the body (bone and liver metastases).
How much weight do you give to a hgb/hct threshold versus symptoms?
Insurance won't pay for harvesting if the transplant is not done within a year.
The patient initially received definitive therapy with AC-T and RT to the breast as well as RT to a solitary bone lesion. She has been on AI for the l...
Are there specific clinical, patient, or disease factors you focus on?
Does this data change your preferred first line treatment regimens when considering other options such as mAb combos, cytotoxic chemotherapy?
Is the non-inferiority margin of 1.429 sufficient, how was this selected?
Is the open label (rather than blinded) study design of any concern?
Is th...
Can experts comment on fungal pneumonia risk with individual BTK inhibitors as seen in ELEVATE-RR and whether this impacts their management decisions?
Do you feel comfortable with BTK inhibitors in these patients?
In ELEVATE-RR patients on a/c were excluded, and rate of atrial fibrillation in the ac...
Such as patients with specific underlying cardiovascular risk factors or other medical comorbidities?
Would you use MRD status to guide your decision making?
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
Patient previously had prostatectomy and salvage RT
How would non-regional adenopathy change management? What about poor surgical candidacy?
Is leukocytosis and thrombocytosis alone an indication for treatment?
If so, venetoclax/dexamethasone by itself or do you include a PI?
Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?
The patient was started on a beta blocker, as this is standard in the area.
Do you ever recheck JAK2/CALR/MPL/BCR-ABL? Would you recommend a bone marrow biopsy? Is cytoreductive therapy indicated?
Is there a role for aspirin or hydroxyurea? Do you perform phlebotomy, and if so, what goals?
Would you consider using infigratinib after progression on pemigatinib?
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
The patient has extensive liver metastases and a high bilirubin. She has not received any prior systemic therapy in the metastatic setting.
In the case of subtle single lineage dysplasia with normal cytogenetics, do you routinely perform NGS testing for CHIP-type clonal mutations?
Do you ...
Recommendations in guidelines are discordant (ASCO vs NCCN vs UptoDate).
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
The patient has an intact uterus and has failed all available AI therapies due to multiple intolerances.
Would you consider neoadjuvant or adjuvant treatment and if so, which therapies? Patient initially had pT2N0 disease and recurrent disease is also ER+...
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
What if the patient is no longer responding to steroids?
Patient had estradiol level checked by her gynecologist due to recent irregular bleeding. Estradiol level was markedly elevated on initial testing (90...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Would you continue pembrolizumab? Would you introduce olaparib? If using both, how would you sequence? Does capecitabine have any role?
Would radical prostatectomy and PLND suffice or would a cystectomy be warranted (even in the absence of bladder involvement) as well?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
How do you stage? Like nasopharynx or p16+ oropharynx?
Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...
If no direct invasion into prostate from bladder or urethra, is there any role for systemic therapy?
Will PD-L1 status impact your decision?
Any role for surgical extirpation vs systemic treatment?
Aside from chemoradiation, are there situations in which you might consider this alternate schedule?
Would you debulk with neoadjuvant therapy to achieve resectability?
Is there data that it actually helps ?
What kind of discussions are you having with your patients regarding the atezolizumab withdrawal?
Front-line PARP inhibitor maintenance therapy discontinued without progression.
Do your recommendations differ between those who receive ABVD and escalated BEACOPP?
Do you recommend consultation with fertility specialists for all...
When do you use mitotane?
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
Especially with the current drug shortage of nelarabine.
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
Patient was on tamoxifen when progression occurred; unable to tolerate adjuvant AI.
How would this affect adjuvant radiation plan in breast conservation therapy patients and mastectomy patients?
Will you incorporate carboplatin into the backbone as it was done in the KEYNOTE trial?
Patient had an initial tumor response to TCHP, but still had significant residual disease present, including positive lymph nodes and residual breast ...
How do you decide between entrectinib or crizotinib? Since no head-to-head comparison, can real world datasets (such as Doebele et al) be used to comp...
What therapy would you offer if the patient had a baseline grade 2 neuropathy?
While building a trusting patient-physician relationship, what therapies could be discussed that may be aligned with naturopathic medicine? (i.e. L-gl...
Does not meet Olympia trial indication
In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...
Is it safe to challenge with other CD20 monoclonal antibodies such as obinutuzumab?
Does patient age effect your approach?
Would you consider RPLND for any patients in light of the phase II SEMS trial presented at the 2021 ASCO GU Ca...
What determines duration of therapy in patients who achieve stable disease or no evidence of disease on imaging?
Is there any role for radiation in t...
This question arises from a case of a patient with multifocal nodular melanoma with circumferential involvement of the perianal region.
Or would you recommend upfront resection as long as borderline resectable?
Do you have a specific age cutoff?
The patient was started on chemoimmunotherapy 3 years ago. Recent scans show small treated brain metastases (s/p RT several years ago) and no disease ...
Presuming that work-up for cardioembolic sources is negative, how would you proceed?
Would you get bone marrow biopsy periodically? Would your approach change based off specific age or platelet count?
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
Would appreciate expert opinion on when to reimage and when to restart anticoagulation depending on findings.
Patient is <60 years old
Patient with T2N1 disease and isolated liver metastases. Axilla and liver completely responded to chemo + IO, but limited residual breast enhancement ...
Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
AIM or doxorubicin/cisplatin? Would you recommend adding methotrexate?
Would your treatment approach be similar for a patient with suboptimal performance status?
If yes would you delay initiation of antineoplastic therapy to allow time for the vaccine to start acting?
Is this a reason to start hydrea? Would you give oral iron after adequate control on hydrea?
Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?
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...
Length of temozolomide course when given with adjuvant radiotherapy
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
No sentinel lymph node biopsy was performed
How would the use of Oncotype guide your management in the neoadjuvant setting?
Based on pCR and EFS data from KEYNOTE 522 and recent FDA approval?
Can adjuvant durvalumab or other I/O or osimertinib (if EGFR+) be considered?
While there are many factors involving:- type (DVT vs PE, unprovoked vs provoked) and severity of venous thromboembolism (VTE) size- duration of antic...
Do prior treatments for mHSPC change your thinking on whether or not to use sipuleucel-T?
Patient has not had any prior systemic treatment and is cisplatin-eligible.
https://pubmed.ncbi.nlm.nih.gov/34077237/
Although a small subset, do you generally move these patients directly on to chemotherapy +/- immunotherapy or does it depend on the specific mutation...
If all work-up including peripheral flow, bone marrow biopsy, PET-CT returns negative, what additional management (if any) would be recommended?
When do you start treatment in this case?
Are there any chemotherapy regimens that can be used in elderly patients with poor PS who are not candidate for BEP?
Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...
In particular, is there any data on the efficacy of Ipilimumab/Nivolumab?
Given that risk definitions are based on size, mitotic activity, location and not necessarily genetics/biology, would an otherwise low-risk GIST, who ...
What factors make you more likely to offer or omit chemotherapy?
What is the role for adjuvant versus neoadjuvant chemotherapy?
While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...
While this is a known risk factor for venous [Meijers et al NEJM 2000] and potentially arterial [Yang et al, Am J Clin Pathol 2006] thrombosis, it is ...
Would active vasculitis present a contraindication to therapy?
What doses and constraints do you use?
If a patient has a large femoral metastasis that cannot be resected, but is to be stabilized with ORIF which will push tumor into the distal end of th...
In reviewing the data, LDH does not upstage to intermediate risk but those patients tend to do worse.
Would one treat this patient as intermediate ri...
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...
Given that olaparib was given within 12 weeks of completion of standard adjuvant therapy on the trial, will you still offer it to patients outside tha...
Patient has been treated with carbo/etop/atezo, WBRT, and maintenance atezo. Currently on high-dose steroids. Would you consider hospice or trial chem...
Results of AHOD1331 are not yet known, but adults have started using Brentuximab upfront for high risk patients
Patient with hepC and advanced cirrhosis with multiple liver mets, but may be able to tolerate oral TKI or PARP. Would you offer this or focus on hosp...
Such as patients who are frail, elderly, renally impaired?
Would you consider sirolimus over cyclosporine or tacrolimus for safer nephrotoxicity prof...
This involves the primary site responding but progression with new bone marrow involvement with resulting cytopenias.
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?
Does the site of treatment factor into your decision?
What adjuvant therapies would you recommend?
If starting with entrectinib would you still try crizotinib, or move to lorlatinib or another novel TKI? Or change entirely to chemotherapy, immunothe...
Are there any clinical features that can inform etiology/which medication to hold?
No targetable mutations detected
How often do you monitor ADAMTS-13 levels off therapy?
For example, do we prefer one regimen over the other in patients with a bleeding history or who have relapsed after a lengthy remission?
Is there any role of radiation therapy for these patient for symptomatic relief?
Performance status is excellent. Second surgical opinion has also confirmed need for amputation, as the recurrence is now breaching intra and extra ar...
Negative surgical margin, normal post-orchiectomy markers and no lymph node and distant metastasis
In addition to ADT, would you treat with abiraterone, enzalutamide or docetaxel? Or other treatment - platinum/taxane?
Osteosarcoma conventional type of the distal right femur. cT1N0M0 G3 Stage IIA on MAP protocol completed NACT followed by surgery on radical resection...
The patient was diagnosed with Ewing’s Sarcoma at the age of 10 and completed 6 cycles of vincristine, ifosfamide, etoposide, adriamycin 75mg/m2...
How is this impacted by patient features, cytogenetics/disease biology, depth of response, or other factors? What would compel you to continue 3 drugs...
How do you factor in patient age, frailty, patients with underlying organ dysfunction, or other clinical features?
Do you still consider CyBorD or R...
Do you have a preference for bicalutamide? Can abiraterone be used instead?
Is DFS benefit in KN-564 in ASCO2021 sufficient evidence to change practice?
History of CDH1 mutation and prophylactic gastrectomy in 2017 - no other primary site found beyond vagina at diagnosis.
Vaginal tumor completely resp...
Can chemoradiation be curative without maximal debulking TURBT?
e.g. a genetic mutation picked up through a family member
In patients who have completed all adjuvant therapy. Similar test to what is available for stage 2 and 3 colon cancer patients by Natera.
Do you opt for VRd, DaraRD, CyBorD or another regimen?
How would this change for a patient with high risk cytogenetics?
Do any studies support this rationale? Does the presence of a somatic vs germline BRCA mutation impact your decision?
In your experience, do certain regimens have more cumulative toxicity, financial impact, or patient convenience factors?
Would you extrapolate treatment from the paradigm of anal SCC?
Do you recommend therapeutic phlebotomy to a certain Hct goal? Any strong evidence for thromboembolic risk related to erythrocytosis or if this is mit...
Given OlympiA trial now showing benefit for BRCA+ patients?
Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...
Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
How do you manage the initial event, including length of steroid taper and the role of pancreatic enzyme monitoring?
What is your experience of subse...
Is your decision swayed by RB1 status or by duration since platinum therapy?
MiT subfamily translocations = TFE3, TFEB, TFC, or MiTF
Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...
Assuming FDA approval of the drug for adjuvant use, do you perceive a difference between somatic vs germline BRCA mutations?
Patient is on fulvestrant+CDK 4/6 inhibitor and with NED for 5 years. In which cases would you consider stopping CDK 4/6 inhibitor?
Given long term data from Keynote 052 for pembrolizumab presented at ASCO 2021.
What factors impact your treatment decisions?
For cis-ineligible PD-...
Gleason 4+3=7 and PSA 4
Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.
Initially treated with definitive chemoRT but recurred with distant mets. Completed 6 cycles carb/tax/bev with minimal toxicity. Excellent performance...
If given both options, which donor would one prefer: haploidentical related donor or 7/8 mismatched unrelated donor using post transplant cyclophospha...
NCCN guideline V4.2021 DLBCL page BCEL-3 states stage I-II, bulky >= 7.5cm should be treated with 6 cycles of RCHOP, but most bone lymphoma studies...
This patient had resection of the primary, requiring multiple resections to obtain an R0 resection, followed by adjuvant radiation to the primary. The...
Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC.
Will you alte...
Are there specific clinical factors, efficacy, or treatment tolerability issues that lead you to favor one agent over another?
How do you compare or ...
IMPower110 data add further support to use of checkpoint monotherapy; however guidelines continue to support either I/O monotherapy vs chemo-immunothe...
What has been your experience with safety of this approach?
How would your management differ in pre- and post-menopausal females?
Would your approach differ if patient is premenopausal or postmenopausal?
Do you discuss patient visits and associated costs when making this decision?
Is there any difference between anticoagulants in this clinical context (e.g. anti-Xa inhibitors vs warfarin vs LMWH)?
There are many delivery methods of cannabis, including smoking, ingesting it through food, or inhaling it. Is one method more effective than another?
We usually recommend copper IUDs, but that's not feasible in all women.
Is there a role for empiric antibiotics if there is history of opportunistic infection?
The ALTA and ALEX trials showed better PFS with brigatinib v. crizotinib and alectinib v. crizotinib. How do you choose your first...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
38 y/o female had a biopsy of a palpable mass that showed G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 c...
Are there other adverse features aside from seminal vesicle invasion, positive margins, or extraprostatic extension that you consider?
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...
Lung is biopsy proven met cervix, SBRT is planned.
Patient did not previously receive para-aortic radiation. Considering RT vs RT + chemo vs chemo alone
Are there any effective non-pharm or pharm interventions?
Does your decision for 3 vs 6 months of treatment change for low risk stage III colon cancer?
Would you plan straight pediatric dosing using 2500 Units/m2 or a cap of 3750 Units as used in some adult ALL regimens due to excess liver/pancreas to...
Patients can develop sensory and motor symptoms such as paresthesias, jaw/facial pain and stiffness, cramping and twitching, ptosis and vision changes...
Biopsy of other sites is more consistent with carcinoid tumor.
Is chemoradiation a viable strategy in osteosarcoma?
Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...
s/p optimal debulking.
If this was an early-stage cancer would it change your adjuvant therapy recommendations?
Healthy 67 y/o woman, 1.5cm tumor, grade 3
Would you consider induction: TPF vs cis/gem or would you proceed with chemoradiation with cis/RT and consider adjuvant cis/5FU?
eg LVI/PNI, poorly differentiated? If so, what regimen and for how long?
Does the rate of progression of IgM influence your decision?
If so, how do you sequence it? Would you consider before adjuvant radiation vs concurrent with adjuvant (chemo)radiation vs after adjuvant radiation? ...
What is the current data regarding acquired resistance mutations for ALK?
Should newer agents such as lorlatinib be reserved for later lines a...
Given antiangiogenic activity, is any TKI an option?
If so, would you recommend adjuvant chemotherapy and PCI after?
Does having a concurrent consumptive process e.g. DIC change your management?
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.
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...
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 ...
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 ...
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?
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...
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...
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?
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?
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-T790M 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?
Is data available regarding the percentages of patients in each arm who underwent staging PET or the breakdown of CNS imaging modalities?
If patients do recur, do you perform these tests on the initial surgical specimen or on tissue from a fresh biopsy (or both?)
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?
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?
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?
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.
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 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?
Patient case is triple positive inflammatory breast cancer
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...
Following chemoradiation, would you consider maintenance durvaluamb as for NSCLC even given the SCLC component?
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)
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...
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.
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...
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?
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.
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?
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?
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?
Is there evidence for radiation therapy in this setting?
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...
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?
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
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Especially if you don't have trials available at the moment.
Would you try off-label erdafitinib (given recent data on bladder cancer) or 2nd line ge...
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?
How do you approach pathologic review and genomic testing, if indicated, of a spindle cell neoplasm?
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?
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.