Non-small cell lung cancer   

Questions discussed in this category


Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear. 

The patient remains without evidence of systemic disease outside of the CNS on serial imaging. Would you continue treating with SRS as lesions appear,...

Given data presented at ASCO 2020? https://meetinglibrary.asco.org/record/191929/abstract

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? 

Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?

Does tumor location play a role (central vs peripheral) in making the decision?  The question stems from an oral presentation at ASTRO 2014 inves...

How do you approach this given the limited # of patients this applies to?  Checkmate 017 and 057 only had 5-7% of patients still on nivolumab at ...

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

Are the other options of chemotherapy that can be used instead of platinum based doublets, including with paclitaxel? 

NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?

Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?

Would you reserve TKI for after standard of care chemotherapy and immunotherapy or consider earlier line of treatment?

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

Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.

Do you feel it is important to start durvalumab within 14 days of completing cCRT?  What real life challenges do you face in doing so and wh...

Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...

If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?

Is the timing of progression (in relation to chemoradiation) a factor, and is there any role for repeat PD-L1 testing at the time of progression?

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

For example, would you modify your SBRT dose next to the azygous vein? While we talk frequently about OAR constraints for the great vessels, it seems ...

I am treating a left lower lobe NSCLC and my PTV is so close to the spleen that a small portion of the spleen is getting significant dose.  I can...

As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula? Currently we would recommend esophagea...

What would you anticipate with regard to potential adrenal toxicity when the patient has only 1 functioning adrenal gland? There are no other sites of...

Does EGFR+ status influence your decision? What is the significance of this finding and its potential for progression? Is it simply occult disease con...

I see the LungTECH trial dose constraints, but, they seem really conservative when you have something large and close the PBT resulting in use of 60 G...

Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...

Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?

If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?

If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...

Would your answer differ based on whether the patient is receiving concurrent chemotherapy? Are there other factors that would influence this decision...

Do you prefer breath-hold techniques (ABC, DIBH) or abdominal compression regardless of tumor motion? Or do you use a general threshold number of cc's...

Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?

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

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

In a patient with a cavitated lesion with underlying chronic infection (identified as cocci) and SqCC, are there additional risks to SBRT? Should spec...

In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...

If so, what constraint is most clinically relevant? The EORTC LungTech trial (60Gy/8 fractions) does not specify a chest wall constraint. I have...

For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...

Do you discuss this at the first consultation? Is there strong evidence to suggest that risks are significantly increased compared to upfront lobectom...

Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?

Is local control worse for SBRT when the tumor is invading into the bone (rib)?

Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?

I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...

For example, a NSCLC of the LLL abutting and potentially involving the adventitia of the descending aorta?

For a patient with a new contralateral primary or recurrence and previous pneumonectomy, what lung constraints do you prioritize (ex mean lung dose, V...

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...

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

Is there a role for SBRT to the primary site? Is it required to treat the ipsilateral hilum if no adenopathy was seen on EBUS or PET?

Have you ever seen toxicity related to diaphragm dose with conventional fractionation?  


Papers discussed in this category


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Cancer, 1998 Mar 15

International journal of radiation oncology, biology, physics, 2012-11-01

JAMA, 2010-03-17

International journal of radiation oncology, biology, physics, 2017-03-15

International journal of radiation oncology, biology, physics, 2015-11-15

Radiother Oncol, 2013 Aug

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2016-10

International journal of radiation oncology, biology, physics, 2016-12-01

Practical radiation oncology, 2018

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2005-09-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2007-05-01

Medical and pediatric oncology, 1990

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1986-01

N Engl J Med, 2017 Nov 16

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

Lancet (London, England), 2017-01-21

The Lancet. Oncology, 2016-11

The New England journal of medicine, 2018-05-31

International journal of radiation oncology, biology, physics, 2009-04-01

J. Clin. Oncol.,

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

The New England journal of medicine, 2017-06-22

Clinical lung cancer, 2016-11

International journal of radiation oncology, biology, physics, 2006-07-01

International journal of radiation oncology, biology, physics, 2007-10-01

The New England journal of medicine, 2018-12-13

Radiat Oncol, 2015 Apr 26

Clin Lung Cancer, 2017 Jul 10

J Thorac Oncol,

Clinical lung cancer, 2018-07

Int. J. Radiat. Oncol. Biol. Phys., 2017 Mar 15

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2016-06

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-12-10

International journal of radiation oncology, biology, physics, 2007-02-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-09-01

International journal of radiation oncology, biology, physics, 2012-05-01

International journal of radiation oncology, biology, physics, 2012-02-01

International journal of radiation oncology, biology, physics, 2010-03-01

Journal of radiosurgery and SBRT, 2011

The New England journal of medicine, 2018-11-22

The Lancet. Oncology, 2017-07

International journal of radiation oncology, biology, physics, 2017-06-01

JAMA oncology, 2018-01-11

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2015-08

Clinical lung cancer, 2015-11

Am. J. Clin. Oncol., 2007-06-01

Medicine (Baltimore),

Eur Radiol, 2016 Mar 04

The New England journal of medicine, 2018-06-14

Medical physics, 2011-11

The Lancet. Respiratory medicine, 2017-11

Clin Lung Cancer, 2017 Mar

Lancet (London, England), 2009-08-01

Lung Cancer,

Lancet Oncol., 2008 Jun 24

Int. J. Radiat. Oncol. Biol. Phys., 2010-06-01

International journal of radiation oncology, biology, physics, 2013-03-01

Respir. Res., 2018 Apr 24

International journal of radiation oncology, biology, physics, 2011-10-01

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

JAMA oncology, 2017-05-01

Int. J. Radiat. Oncol. Biol. Phys., 2008 Jan 30

Thorac Surg Clin,

International journal of radiation oncology, biology, physics, 2013-04-01

International journal of radiation oncology, biology, physics, 2014-04-01

International journal of radiation oncology, biology, physics, 2015-09-01

N. Engl. J. Med.,

PLoS ONE, 2015 Nov 24

J. Clin. Oncol., 2015 Nov 02

JAMA oncology, 2019-07-01

Future Oncol, 2019 Apr 25

Lancet (London, England), 2016-04-09

Clin. Cancer Res., 2018 Oct 08

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

J Thorac Oncol, 2019 Feb 16

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-11-01

The New England journal of medicine, 2011-08-04

Lancet Oncol., 2012 May 22

J. Clin. Oncol., 2019 Dec 11

Lancet Oncol., 2017 Sep 25

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-03-10

N Engl J Med, 2020 Sep 19

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-12-01

J Thorac Dis,

Ann. Oncol., 2015 Apr 28

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-11-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2009-11-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-03-20