Non-small cell lung cancer   

Questions discussed in this category



Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?

How does the changing landscape of first-line treatment impact your decision making for second line therapy?

If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...

This post refers to the recently published RCT by Chang et al., PMID 37478883 investigating lung SBRT with vs. without 4 months of nivolumab for early...

E.g. esophagus? If you crop the esophagus out of the ITV, then your ITV would not fully encompass the iGTV. 

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

The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...

Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?

IMPower110 data add further support to use of checkpoint monotherapy; however guidelines continue to support either I/O monotherapy vs chemo-immunothe...

Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?

Are there scenarios in which you would proceed with checkpoint inhibitor for PDL1+ disease before having full molecular testing results?

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...

Do you consider any neoadjuvant therapy or proceed to surgery followed by adjuvant chemotherapy and osimertinib? Does the type of mutation (ex a rare ...

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...

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

Are there specific clinical factors, efficacy, or treatment tolerability issues that lead you to favor one agent over another? How do you compare or ...

How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?

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 ...

Would you offer adjuvant atezolizumab, osimertinib, or neither? Both IMpower010 and ADAURA only had patients with EGFR exon 19 deletion or L858R mutat...

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

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

Is there anything to differentiate the two agents? CNS penetration reportedly with adagrasib, FDA accelerated approval has been given with sotorasib.&...

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...

How do you operationalize finding biomarker information in EHRs/testing portals, either for your own patients or if they have changed providers? If a...

How are your teams effectively evaluating and counseling patients to ensure they are prepared for potential extended adjuvant treatment approaches? Is...

If a patient is asymptomatic at presentation, how do you incorporate local treatment options (RT/surgery) and when?

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

Is there a certain time interval where you would feel comfortable to rechallenge with immunotherapy at recurrence (6m vs 1y vs 2y?) Does degree of PDL...

Are the experts convinced by DFS when the OS is immature?  How many in BSC arm went on to receive immunotherapy and was that adequate?

What would you do for a patient with a non-EGFR actionable mutation?IMpower010 included EGFR and ALK mutated NSCLC. Is there any concern in the use of...

Do you initially start with systemic therapy alone or do you proceed directly to chemo-radiation? 

What is your general rationale for selecting from available options?

How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?

E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.

Although a small subset, do you generally move these patients directly on to chemotherapy +/- immunotherapy or does it depend on the specific mutation...

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

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?

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?

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

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? 

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.Antonia et al., PMID 28885881...

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?

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...

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 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)?

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)?

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

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

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

Clinical lung cancer, 2016-11

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

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

Pulmonary medicine, 2012

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Clin Lung Cancer, 2017 Jul 10

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Clinical lung cancer, 2018-07

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

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J Clin Oncol, 2022 Jun 03

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

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Journal of radiosurgery and SBRT, 2011

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

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J Clin Oncol, 2020 Aug 11

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Eur Radiol, 2016 Mar 04

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Lung Cancer,

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