Non-small cell lung cancer   

Questions discussed in this category


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.&...

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

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...

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...

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

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

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

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?

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

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? 

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.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?

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 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)?

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

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

Pulmonary medicine, 2012

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

Lancet (London, England), 2014-08-23

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

Lancet Oncol, 2019 May 20

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

The New England journal of medicine, 2017-08-31

Ann Oncol, 2020 May 11

N Engl J Med,

J Clin Oncol, 2020 Aug 11

J Thorac Oncol,

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

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

Thorac Cancer, 2017 Apr 24

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

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Thorac Surg Clin,

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

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Practical radiation oncology, 2016

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PLoS ONE, 2015 Nov 24

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-01-01

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

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

The New England journal of medicine, 2014-11-13

Lancet Oncol., 2017 Sep 11

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

J Clin Oncol, 2020 Dec 04

J Thorac Dis,

Ann. Oncol., 2015 Apr 28

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

JCO precision oncology, 2019

Annals of oncology : official journal of the European Society for Medical Oncology, 2019-08-01

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Annals of oncology : official journal of the European Society for Medical Oncology, 2016-07

Clin Lung Cancer, 2020 Feb 10

Clin Oncol (R Coll Radiol), 2017 Nov 16

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2014-06

Radiother Oncol, 2020 Jul 31

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

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Cancer Sci,

The Lancet. Oncology, 2015-07

The Lancet. Respiratory medicine, 2019-05

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ESMO Open, 2021 Oct 01

J Clin Oncol, 2021 Apr 19

Lancet Oncol, 2021 Jan 18

N Engl J Med,

Lancet,

Ann. Oncol.,

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2018-08

J Thorac Oncol, 2021 Jul 08

Lancet (London, England), 2019-05-04

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J BUON,

Br J Cancer, 2019 Sep 30

The New England journal of medicine, 2005-06-23

Lancet Oncol., 2006-09-01

J. Clin. Oncol., 2008-07-20

The Lancet. Oncology, 2017-12

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International journal of radiation oncology, biology, physics, 2015-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-05-20

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The Lancet. Oncology, 2017-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-04-20

JAMA Oncol,

Clin Lung Cancer, 2021 Jan 27

Eur J Cancer, 2021 Apr 01

Lancet Oncol, 2019 Oct 25

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Lancet Oncol, 2016 Apr 12

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World J Clin Cases,

Br J Cancer, 2016 Nov 22

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