NCI-CCC Tumor Board Question
These are questions being discussed by academics at NCI-Cancer Centers
Questions discussed in this category
What is your specific therapy choice and duration?
Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?
Would you consider gene profiling to determine need for chemotherapy?
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
In a patient who is not a surgical candidate, do you offer concurrent carbo/taxol rather than 5FU/oxaliplatin?
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.
How do clinical risk and Mammaprint/Oncotype scores affect your decision?
For example, will you recommend a certain vaccination timing in relationship to their treatment? Any concerns for reduced immune response or risks of ...
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...
What factors would determine your consideration of this as a recurrence versus a new primary and how would that influence your decision?
Does tumor size impact your recommendation? High grade? Young patient age?
Does the advent of more effective therapies like peptide receptor radioligand therapy (PRRT) and capecitabine and temozolomide (CAPTEM) dampen enthusi...
Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.
Would you consider ALND and /or XRT to axilla?
Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy.
Would you use FOLFIRINOX as in Prodige 23 or FOLFOX as in RAPIDO?
If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.
Chemoradiation completed 1.5 years prior
Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?
The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.
Both ARTIST and Inte...
Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...
Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.
Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?
SRS done to the single brain met, PD-L1 5%, BRAF G469A mutation
Would your answer change if the new lesion is ALH/ADH?
Would you consider it for a patient who had bulky thoracic disease, only a single extrathoracic site of involvement and achieved a CR after induction ...
Is immunotherapy plus chemotherapy now standard of care for small cell lung cancer, even though overall survival differences are small? Are there any ...
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,...
Would you recommend additional cytotoxic chemotherapy and/or switch her anti-Her therapy to T-DM1?
For a patient with high risk disease and a severe enough reaction that additional taxane-based therapy is contraindicated, do you consider alternate c...
Is there an advantage to early diagnosis and intervention versus observation until the nodules are amenable to percutaneous biopsy?
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?
Patient completed adjuvant AC-T 8 months prior to recurrence. BRCA negative, foundation medicine NGS pending.
PD-L1 is low and she has residual neuropathy from neoadjuvant paclitaxel.
What are there most evidence-based options?
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 ...
Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.
Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?
If yes, would you offer tamoxifen or ovarian suppression plus AI?
This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...
Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...
Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?
Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?
Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?
Would you continue to trend ctDNA to detect early recurrence?
Upfront surgery vs neoadjuvant therapy? And if neoadjuvant therapy, which regimen?
Patient has a good PS.
What are the risks of infection with COVID-19 if using immunotherapy?
Would your choice vary based on the patient's gender?
Should staging and treatment decisions be made based on imaging alone?
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 ...
If so, how long is too long to wait?
This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.
Do you ever consider stopping if stable disease and good tolerance?
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...
Most trials establishing CRT as standard of care for IIIB NSCLC excluded patients with separate ipsilateral lung nodules given that they were categori...
Would you treat this differently than someone who only presents with axillary nodal disease?
In your experience, what approach has been successful to bridge to surgery?
How, if any, do you utilize genomic testing to guide systemic therapy?
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...
Additionally, would the finding of any mutations, such as ESR1, change your recommendation?
For example, is this still your approach in women with small tumors or node negative disease?
If so, for what platelet count threshold and do you have a preference as to which agent?
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...
PET-CT and Brain MRI are negative for other evidence of disease.
Would nivo + Ipi be appropriate in this situation, especially if high TMB?
Especially in light of the new Guardant data presented at AACR 2019
In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?
Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...
What would be the next line of treatment, PRRT, capecitabine and temozolomide or other?
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...
The NCCN guidelines regard MET exon 14 skip mutation as an emerging biomarker but no formal recommendation to start crizotinib. If high P...
Is there any advantage of one regimen over the others?
Is this new SSO choosing widely guideline being widely adopted and are there any concerns regarding this for clinical practice?
If finished adjuvantly, what would you do -- continue TC or change chemotherapy?
If yes, would you still recommend dual HER2 directed therapy?
After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...
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...
If so, what is your approach to sequencing and timing of targeted therapy and local therapy?
RP node with treatment related changes and surgical specimen from TAH/BSO no other foci of malignancy found.
I have seen anywhere from 4-6 months utilized. Is there any data to guide your strategy?
Does your approach differ by EBV status?
Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...
If so, after how many cycles of chemotherapy would you switch?
Does hormone receptor status impact your decision?
Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?
Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.
In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...
If so do you favor repeat tumor biopsy or cfDNA?
Would you forego anthracycline?
In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial.
https://www.ncbi.nlm.nih.go...
Do you see a role for adjuvant radiation therapy?
http://abstracts.asco.org/239/AbstView_239_262655.html
If so, would you combine them vs monotherapy? Patient ECOG is 1
Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?
If so, would you treat as node + BC with anthracycline and taxane regimen or non-anthracycline regimen (i.e docetaxel and cyc...
greatest measuring 1.0cm.
Or would you proceed with standard-of-care adjuvant approach for high risk patients?
I.e. according to Mammaprint test?
Retrospective data suggest clinically significant disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung canc...
The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...
Would you use Lorlatinib , chemotherapy, immunotherapy or Chemo- immunonotherapy?
Patient did not receive neoadjuvant therapy.
If it is still within the 12 month period and no disease recurrence?
Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?
Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...
If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?
Would you give adjuvant chemotherapy or start osimertinib?
The CALOR trial included patients that could receive HER2-targeted therapy.
Some retrospective data reports that STK11 (AKA LKB1) makes NSCLC resistant to immunotherapy.
No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.
Would you consider neo-adjuvant chemotherapy or treat with endocrine therapy?
Do your recommendations differ if patients are pre or postmenopausal given the data?
Have the results from IMpassion130 changed the standard of care?
Does the answer vary based on whether it is neo/adjuvant or metastatic setting?
How applicable is the SOFT/TEXT data in this setting ?
Would you consider radiation and/or chemotherapy?
Initial pathology additionally yields low Ki-67 and is HER2 negative.
What if the patient has thymoma-associated myasthenia gravis?
Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?
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...
All tumors in this case were <2cm in size.
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
(HER2/CEP17 ratio <2.0, copy number >4.0 and <6.0 signals/cell)
There is no evidence of disease outside the lung on PET, and the patient is completely asymptomatic with negative EGFR, ALK, ROS1, and BRAF and a PD-L...
PD-L1 < 50% and no targetable mutations. Would you use carbo/pemetrexed/pembrolizumab or Nivolumab or pembrolizumab?
How does the timing of recurrence play into your decision?
Lung primary is inaccessible for biopsy and metastatic sites are only 2 small bone lesions. In a non-smoker, a driver mutation is suspected but would ...
Would you offer adjuvant therapy post resection?
In the setting of the recent TailorRx data, would these patients be considered more high risk?
Pt is healthy and tolerating Tamoxifen well.
In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...
Can these patients be re-challenged with Herceptin?
Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...
Would you do this for ER+ patients?
According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...
If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, ulcerated breast.
High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.
Pt clinically has inflammatory breast cancer making mastectomy a poor option.
First episode was 10 years ago and patient did not receive XRT. Would you give XRT now?
Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?
Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
These patients have been largely excluded from these trials. What if the infection is well controlled?
An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...
If so, when? Are there certain ERBB2 mutations that would predict response to trastuzumab and/or neratinib?
Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
What do you do with low grade (grade 1/3) tumors? In other words, does high grade pathology over rules?
Would you use a regimen with lower incidence of neurotoxicity such as CMF or a taxane-based regimen with a low threshold to dose-reduce?
Some patients request chemotherapy scheduling adjustments to avoid feeling ill on major holidays. Delaying chemotherapy by a few days isn't of particu...
Example case: Patient given neoadjuvant docetaxel + cyclophophamide achieves a partial response after 3 cycles of Taxotere + cyclophosphamide but is u...
How often will you monitor it? In the setting that patient is morbidly obese, does your strategy change?
Tamoxifen prophylaxis is FDA-approved, but would you extrapolate from adjuvant/metatastic data for hormone receptor positive breast cancer in post-men...
In the absence of data demonstrating a clinical benefit for one strategy versus the other, what do you do in practice?
There is limited data that suggests steroidal AI exemestane could be of some benefit after nonsteroidal AI failure (Lonning PE et al. J Clin Oncol 200...
For example, would you order a PET/CT to evaluate for lymphatic or distant metastatic disease?
Does your institution do this routinely?
I.e. either for treatment of high-risk disease or intolerance/contraindication to tamoxifen. Will you continue it for the full 5 year course?
Do you prefer doing this through a "neoadjuvant" approach vs. post-operatively?
CALOR trial
How does the modest results of the APHINITY trial impact your practice?
In a patient with isolated leptomeningeal disease (no systemic disease), would you still recommend systemic therapy?
Do you reserve this approach for only women with triple negative breast cancer or all-comers?
Is this in addition to or mutually exclusive from oncotype/mammaprint?
Patient has hormone-refracatory disease, had high visceral burden (pulmonary mets, bone, lymph). Progressed on taxane, xeloda, gemcitabine. Now ...
What would you choose if there is no response to neoadjuvant AC-T? Taxol, THP, TCHP?
(For instance, TCX4 instead of AC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemotherap...
At what point do you send these test, and in what instances do the results influence your treatment recommendations?
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Papers discussed in this category
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