For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?

So, this is a challenging question – actually two questions – 1) unable, 2) refuse.

With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...

For patients with inoperable stage III who are unable to receive chemoradiation (and I think this limitation should be examined carefully), there are several options:

1. Sequential chemo-radiation

2. Radiation therapy alone (standard or hypofractionated)

3. Treatment as if the patient had stage IV dise...

I think the clinical scenario would define the best option here.

On the one extreme, of a patient who has good KPS and no contraindications to chemoRT, but who refuses chemo, I would consider 60Gy/30 fx RT alone followed by Durva.

If a patient had poorer KPS, and a more limited field size, I would con...

Radiation alone. Hypofractionation could be employed... 45-60Gy/15fx with imrt/igrt.

https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2016/Hypofractionated-radiation-therapy-can-halve-treat

immunotherapy would probably be a good idea afterwards, but I believe imfinzi/d...

The most toxic component in question is radiotherapy. If this patient has several nodal stations or significant primary tumor size needing wide radiation fields, if it was me personally as a patient I would prefer to be treated particularly if high PDL1 positive, or high tumor mutational burden with...