Thoracic Malignancies&nbsp;&nbsp;&nbsp;

How do the results of CheckMate 9LA and subsequent FDA approval of nivo+ipi+chemo impact your first line management of patients with non-small cell lung cancer?

How do you decide between checkpoint monotherapy versus chemo-immunotherapy approach for patients with PD-L1 High (>50%) NSCLC?

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

7 Answers available

Are there any situations where you would consider neoadjuvant chemoradiation as opposed to chemoimmunotherapy for patients with resectable NSCLC prior to surgical resection?

In a patient with extensive stage small cell lung cancer and a neurologic paraneoplastic syndrome do you feel comfortable using an ICI along with the chemotherapy?

Would you ever switch capmatinib to tepotinib or vice versa for patients with NSCLC with MET ex 14 skipping mutation who are responding to treatment but with ongoing edema despite dose reductions?

How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?

I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...

What is your current practice for obtaining PD-L1 and mutation testing for newly diagnosed metastatic NSCLC?

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...

How do you choose between neoadjuvant chemotherapy alone vs neoadjuvant chemoradiation in patients with potentially resectable stage III NSCLC who are not upfront surgical candidates?

Outside of a clinical trial, what is your preferred third-line systemic therapy option for a patient with relapsed/refractory ES-SCLC?

In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?

Is there any evidence that patients with metastatic NSCLC with KRAS G12C mutations benefit less from treatment with immunotherapy?

Are there patients you currently utilize neoadjuvant TKIs for stage II-III NSCLC?

Do you hold/avoid pemetrexed in patients with NSCLC and pleural effusions?

What are your top takeaways in Thoracic Cancers from ASCO 2022?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?

Do you recommend holding a KRAS inhibitor during palliative radiotherapy?

Would you ever consider definitive thoracic RT with concurrent immunotherapy in Stage III NSCLC?

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 manage a patient with metastatic NSCLC whose initial mutation testing was limited or results are no longer available?

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

What is the optimal treatment strategy for patients with stage IV NSCLC who have an actionable molecular target identified after initiation of first-line systemic therapy?

How do you choose the appropriate first line treatment between everolimus, somatostatin analogues, or cytotoxic chemotherapy in patients with good ECOG PS and widely metastatic atypical carcinoid of the lung?

What are your treatment considerations for a patient with stage IVb NSCLC who is KRAS G12C mutated and PD-L1 high (>50%)?

For patients with potentially resectable stage III superior sulcus NSCLC, do you incorporate immunotherapy in your multi-modality treatment after chemoradiation?

How do you approach the management of capmatinib induced edema?

What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?

How do you approach treatment sequencing in KRAS G12C NSCLC?

Is there evidence or experience to support use of targeted therapy for KRAS G12C mutated NSCLC as first line in place of chemotherapy?

How do you choose between neoadjuvant and adjuvant chemo-immunotherapy for patients with resectable stage II-IIIA NSCLC?

In light of CheckMate 816 and IMpower010 and FDA approval for neoadjuvant chemo-nivolumab and adjuvant chemo-atezolizumab, how do you decide which sys...

How will you decide between neoadjuvant CheckMate 816 approach vs adjuvant IMpower010 approach in a fit patient with EGFR negative resectable Stage II-III NSCLC patient with PD-L1 high expression tumor?

Do you use specific PDL-1 assays for each approach?

Would you consider patritumab deruxtecan on clinical trial instead of chemotherapy for patients with EGFR+ lung cancer progressive on osimertinib?

How would you approach adjuvant therapy for a patient with pT2N2 lung adenocarcinoma who underwent an R1 resection and is not amenable to further surgical intervention?

NGS without any actionable mutations and PD-L1 TPS 15%. Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?

Do you stop PPI when starting patients on immunotherapy?

Do you consider EBUS TBNA in the diagnostic evaluation of patients with mediastinal lymphadenopathy with concern for lymphoma?

Do you offer durvalumab to patients with stage IIIB NSCLC after chemoradiation if they are also on long term dialysis for ESRD?

Are there data for using checkpoint inhibitors in this setting?

Are there situations in which neoadjuvant chemoimmunotherapy + surgery would be preferred over chemoradiation + adjuvant immunotherapy for stage III lung cancer?

How would you manage a patient with Stage IV Non-small Cell Lung Cancer with concomitant atypical EGFR mutation (such as G719D) and atypical ROS1 fusion?

Would you attempt targeted therapy or would you choose chemo-immunotherapy?

Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?

Is this an artifact of what agent prior clinical trials used or something to do with mechanism of action (ie less mineralocorticoid effect of dex)?

Which patients with resectable Stage IB-IIIA NSCLC would most benefit from using neoadjuvant chemoimmunotherapy as per CheckMate 816?

What systemic therapy, if any, would you offer a patient after WBRT for an isolated CNS relapse of initially limited stage SCLC that received chemoRT without PCI?

Would the timing of the relapse (eg within 6 months) impact your decision making?

What are best practices for engaging with multidisciplinary colleagues to ensure patients with earlier stage NSCLC are being appropriately considered for novel adjuvant therapies?

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

How would you approach treatment of a patient with metastatic NSCLC with PD-L1>1% and HER2-mutation?

Does this change for PDL1 1-49% vs >50%? Will you be more likely to employ other checkpoint inhibitors before use of HER2 targeting therapy? Or sta...

For patients who received neoadjuvant chemotherapy and found to have an EGFR sensitizing mutation at time of R0 surgical resection, would you offer still offer adjuvant osimertinib?

For a patient with metastatic NSCLC who had progression x2 at a single site treated w RT, would you switch systemic treatment?

Patient has been on pembrolizumab and had two symptomatic soft tissue mass treated with radiation.

With the recent FDA approval of neoadjuvant chemotherapy and nivolumab for Stage IB-IIIA NSCLC, does the fact that the study used AJCC 7th edition staging impact your patient selection at all since we currently are using 8th edition staging?

How do you approach adjuvant therapy for resected lung adenocarcinoma that was found unexpectedly postop to be N2?

Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase ...

10 Answers available

Would you still consider durvalumab consolidation after definitive chemoradiation for patients with Stage III NSCLC who are on stable weekly methotrexate dosing for psoriasis/psoriatic arthritis?

Would you administer postoperative adjuvant atezolizumab or chemotherapy for patients with locally advanced NSCLC and pathological residual disease following neoadjuvant nivolumab/chemotherapy and surgical resection?

This would “combine” approaches from both Checkmate-816 and IMpower010

What is your preferred systemic treatment for patients progressing during or soon after completion of consolidation durvalumab for unresectable NSCLC?

For locally advanced NSCLC with additional synchronous NSCLC primaries in the same lung or lobe, what is your approach to definitive therapy?

E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...

Would you extrapolate IMPower010 data to offer adjuvant atezolizumab to a patient with N2 PDL1-high (>50%) NSCLC who had been treated with induction chemotherapy followed by definitive R0 resection after partial response?

Can atezo be used even if patient has completed chemotherapy preoperatively?

For a patient with stage 4 lung cancer PDL1 TPS > 50% and long term history of myasthenia gravis stable on mycophenolate, would you ever consider pembrolizumab or would this be absolute contraindication?

How do you decide which immunotherapy agent to utilize for 1st line in PD-L1 high (>50%) NSCLC?

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...

8 Answers available

Is there any role for adjuvant atezolizumab or adjuvant osimertinib in patients who received neoadjuvant chemotherapy for resectable NSCLC?

Would you avoid cisplatin with etoposide in a patient getting chemoradiotherapy for stage III non-squamous NSCLC who has a history of CABG 4 years ago and echocardiogram showing left atrial dilatation?

How would treat recurrent, unresectable thymoma in patients treated previously with CAP and radiation therapy with long interval to recurrence (>2 years)?

For metastatic thymic carcinoma or thymoma, after 6 cycles of chemotherapy (ie cisplatin, cyclophosphamide, doxorubicin) with good a response, what if any maintenance regimen would you consider?

What is your preferred first line treatment approach for a patient with PDL-1 high (>50%) NSCLC presenting with CNS mets?

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

What is your preferred first line treatment option for a fit patient with non-squamous NSCLC who is PDL1 positive (1-49%) with no driver mutations?

Does the 2020 approval of Nivolumab and Ipilimumab for mNSCLC with PDL1 >1% impact your decision?

What high risk features for stage IB NSCLC would lead you to consider adjuvant chemotherapy?

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

How are you approaching patients with Stage IV EGFR NSCLC who progress on first line TKI and are found to have retained EGFR mutation as well as MET amplification?

What are your recommendations for a patient with metastatic non-mutated lung adenocarcinoma who previously had headaches responsive to prednisone but with negative temporal artery biopsy for GCA?

For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...

Would you hold osimertinib in a patient with a STEMI, and for how long?

Would you offer adjuvant chemotherapy, osimertinib, or both to a patient with Stage IB EGFR mutated lung adenocarcinoma found in the lung explant pathology after bilateral lung transplant?

Would you consider the immune suppressed status of the patient as a high risk factor to offer adjuvant therapy?

For which patients with resected NSCLC will you offer adjuvant atezolizumab after completion of cisplatin-based adjuvant chemotherapy?

Will degree of PD-L1 status impact your decision? Would you ever offer to stage IB patients as per study enrollment? Do AJCC v8 staging guideli...

Are there any data for second line nivolumab-ipilimumab in patients with metastatic NSCLC treated with either single agent pembrolizumab or chemotherapy + ICI as first line therapy?

Would you consider second line nivo-ipi for patients with a specific histology or tumor PD-L1 expression?

Do you perform PDL1 and molecular testing for patients with stages I-III NSCLC?

How would use of adjuvant atezolizumab for PDL1+ NSCLC potentially impact your treatment choice at recurrence?

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...

Should 1 year of atezolizumab be the standard of care for stage II-IIIA resected PDL1+ NSCLC?

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 is your recommended adjuvant approach to resected NSCLC with both PD-L1>1% and EGFR mutation?

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 ever withhold PCI for elderly patients with limited stage SCLC?

In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?

How do you approach patients with Stage IIIB/C NSCLC with ipsilateral supraclavicular (N3) disease?

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

How do you manage maintenance therapy in metastatic NSCLC, adenocarcinoma with good response to initial chemo (carboplatin, pemetrexed, pembrolizumab) with borderline renal function that has worsened during initial treatment?

Would you stop all treatment after 4 cycles, or proceed with pembrolizumab alone, and would PD-L1 expression factor into your decision?

Would you consider SBRT and adjuvant therapy for a 4cm, node-negative, non-oncogene driven, NSCLC not amenable to surgical resection?

Are there clinical features that would lead you to consider combining SBRT + immunotherapy in a high risk early stage NSCLC?

How do you interpret efficacy of trastuzumab deruxtecan based on HER2 mutation type and/or level of HER2 overexpression?

How and when do you plan to perform HER2 testing in patients with NSCLC?

In stage II/III node positive patients with driver mutations positive NSCLC who are not surgical candidates and are unlikely to tolerate concurrent chemotherapy and radiation, would you consider radiation alone, TKI alone, or would you ever consider TKI + RT?

What would be the treatment duration if using oral TKI?

Do you find data from phase 2 DESTINY-LUNG01 study sufficient to change practice in HER2 mutant NSCLC or is a phase 3 study still needed?

How does trastuzumab deruxtecan compare to other HER2 targeted strategies?

How would you approach a patient with mediastinal-only recurrence of small cell lung cancer < 6 months after primary surgical resection and adjuvant platinum-etoposide for Stage I disease?

What is your approach to a patient with metastatic lung cancer with HER2 mutant NSCLC who is not a trial candidate?

How are you thinking about sequencing therapies for these patients (IO vs chemo vs T-Dxd)? Are the data from DESTINY-Lung01 strong enough to warrant e...

What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?

Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use? Do you feel the dosing used in...

Are you selecting any specific patient cohort with metastatic NSCLC for treatment with the CheckMate 9LA protocol of ipilimumab + nivolumab + 2 cycles of chemotherapy?

What is your preferred first line regimen for PDL1-negative squamous cell lung cancer?

What is your general rationale for selecting from available options?

Do you recommend postoperative radiation therapy for pathologic T1-2N1 small cell carcinoma of the lung?

If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?

Does concurrent brain and systemic progression alter your choice of systemic therapy for patients with metastatic SCLC with early progression on chemoimmunotherapy and WBRT?

Would you offer topotecan, lurbinectedin, or another agent given the CNS progression as well?

When determining frontline treatment for NSCLC, would you incorporate molecular predictors of resistance to immunotherapy such as STK11, KEAP1, p53?

What factors do you take into account for recommending chemo/IO vs IO/IO vs CheckMate 9LA regimen in front line therapy for PD-L1 negative advanced squamous cell carcinoma?

How do you interpret the comparative efficacy in squamous cell subsets among the CM vs KN studies?

What is your treatment of choice in ALK-positive lung adenocarcinomas that have progressed on alectinib with resistance mutations that are not G1202R?

Do you choose Lorlatinib or brigatinib? Or do you try to add chemotherapy to alectinib?

How would you treat lung adenocarcinoma patients progressing on osimertinib who are not candidates for chemotherapy?

Do you avoid immunotherapy in patients with Stage IV NSCLC with atypical EGFR mutations such as G719S or S768I?

Is it reasonable to offer observation with MRI rather than immediate PCI for patients with limited stage SCLC?

7 Answers available

Would you offer adjuvant chemotherapy, or osimertinib if EGFR+, to patients with two synchronous stage 1A lung cancers that appear to be distinct and have both been resected?

How do you approach management of newly diagnosed locally advanced NSCLC in patients who are intubated for respiratory failure due to their disease burden?

E.g. disease burden causing airway or vascular compression.

How do you incorporate PCI into your management of patients with extensive stage SCLC?

Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...

How are you choosing between ipilimumab/nivolumab versus platinum/pemetrexed for unresectable epithelioid mesotheliomas?

How would you approach synchronous early stage NSCLC adenocarcinoma and locally advanced symptomatic squamous head and neck cancer that is deemed nonresectable upfront?

Would you prioritize the head and neck cancer or treat the lung cancer first with SBRT to take care of it first? How about if there is mediastinal inv...

In the modern era, what volume of involvement is considered limited stage SCLC?

Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?

Do you offer consolidation durvalumab in stage III patients with NSCLC who developed grade 2 radiation pneumonitis during chemoradiation?

How do you approach EGFR mutated NSCLC with isolated progression in the chest who is planned for a course of radiation at least 3-4 weeks?

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

How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

What is your preferred first line therapy for ROS1 rearranged metastatic NSCLC without CNS mets?

How do you decide between entrectinib or crizotinib? Since no head-to-head comparison, can real world datasets (such as Doebele et al) be used to comp...

Can immunotherapy, alone or with chemo, be considered for ROS1+ NSCLC after exhausting ROS1 targeted therapy options?

How would you approach patients with resected, node positive (N1/N2) Large Cell Neuroendocrine Carcinoma of the Lung who have ESRD on dialysis?

How would you treat a patient with stage 4 NSCLC with EGFR R776H mutation?

Would you offer PCI to a patient with LS-SCLC, who presented initially with paraneoplastic syndrome (encephalomyelitis), but had no neurocognitive sequelae after chemoradiation?

Patient is <60 years old

Do you treat atypical carcinoid of the lung with N2 or N3 nodal involvement with definitive concurrent chemoradiation?

Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...

For locally recurrent NSCLC after surgical resection but with subcentimeter ipsilateral nodules of indeterminate etiology, would you consider local therapy such as chemoradiation +/- durvalumab?

Do you have a maximum size cutoff for lung SBRT in central NSCLC?

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

Do you hold immunotherapy when administering lung SBRT?

One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...

Is there ever a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?

In patients with RET-fusion positive NSCLC with symptomatic brain metastases, would you consider starting selpercatinib/pralsetinib upfront or would you proceed with whole brain radiation with TKI to follow?

Would you use a hippocampal sparing technique when treating with PCI for a limited stage small cell lung cancer?

How do you approach less common cutaneous/mucosal toxicities from EGFR TKI and monoclonal antibody therapies, such as ocular (keratitis and conjunctivitis) and genital mucositis (vulvovaginitis and balanitis)?

What would you offer as adjuvant therapy for a resected stage IIIB adeno NSCLC in a patient who refuses chemotherapy?

Can adjuvant durvalumab or other I/O or osimertinib (if EGFR+) be considered?

Is there any evidence that sotorasib is effective in KRAS-driven tumors beyond KRAS G12C?

How do you approach patients with driver mutation positive, Stage IV NSCLC who don't benefit from upfront first-line TKI?

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

How would you approach metastatic adenocarcinoma of the lung with ROS1 rearrangement by FISH and EGFR mutation by NGS?

How do you approach the management of a patient with extensive small cell lung cancer who has progressed on third-line therapy, with borderline functional status, complicated by paraneoplastic CNS syndrome?

Patient has been treated with carbo/etop/atezo, WBRT, and maintenance atezo. Currently on high-dose steroids. Would you consider hospice or trial chem...

How many days do you hold osimertinib during or around SBRT for oligometastatic EGFR mutated advanced lung cancer?

Does the site of treatment factor into your decision?

What would you use as next line of treatment for a patient with ROS1+ metastatic NSCLC progressing on first line TKI?

If starting with entrectinib would you still try crizotinib, or move to lorlatinib or another novel TKI? Or change entirely to chemotherapy, immunothe...

Are there specific ROS1 fusions/mutations that confer sensitivity or resistance to therapy to help guide treatment selection in first line or at progression?

Are there any preferred chemotherapy regimens for Stage IV NUT carcinoma?

Is there any role of radiation therapy for these patient for symptomatic relief?

Would you recommend stent placement upfront in a patient with cervical esophageal cancer and a TE fistula?

How would you treat a patient with squamous NSCLC with NRG1 amplification (no fusion) who has progressed on first-line treatment?

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

When giving single agent docetaxel for patients with metastatic NSCLC who have progressed on platinum and immunotherapy, do you stop after 6 cycles or do you continue as long as tolerated and disease is stable?

What is your preferred second line therapy for patients with metastatic large cell neuroendocrine carcinoma of the lung after progression on first line chemo-immunotherapy?

Is your decision swayed by RB1 status or by duration since platinum therapy?

What is your approach to a patient with an EGFR exon 19 mutated NSCLC who develops progression on osimertinib and repeat biopsy demonstrates the EGFR exon 19 mutation and a new BRAF V600E mutation?

For a patient with metastatic NSCLC, PD-L1>50%, after progression on first line checkpoint inhibitor, do you prefer chemotherapy alone or chemotherapy added to the immunotherapy?

9 Answers available

How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?

Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC. Will you alte...

Is there a role for retreatment with immunotherapy in patients progressing after initial treatment with immunotherapy for metastatic non small cell lung cancer and who achieve complete or partial response at two years?

What is your preferred first line therapy in metastatic ALK+ NSCLC?

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

How do you approach treatment for patients with ALK+ mNSCLC who have multifocal or leptomeningeal CNS progression while on first-line targeted therapy?

Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?

Do you recommend trilaciclib as primary prophylaxis for myelosuppression in certain patients with ES-SCLC treated with first line chemo-immunotherapy?

How do you think about sequencing therapy for a patient with ALK+ metastatic NSCLC given the available options?

What is the current data regarding acquired resistance mutations for ALK? Should newer agents such as lorlatinib be reserved for later lines a...

Would you consider SBRT for an inoperable T1-T2 N0 SCLC?

If so, would you recommend adjuvant chemotherapy and PCI after?

For LS-SCLC with radiographic CR after chemotherapy, is there a time point beyond which you do not offer radiation if there is a delay in initiation of radiation?

Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.

Are there any molecular predictors for response to chemoimmunotherapy for patients with ES-SCLC?

Are you routinely performing molecular sequencing? Would you modify your treatment approach in first or later lines based on PDL1 status?

How do you manage ALK-inhibitor AEs which are low grade but significantly impact patient QOL over time?

Such as dysgeusia, headache, rash, fatigue, etc

How can you adjust neoadjuvant or adjuvant platinum based chemotherapy for stage Stage II-III non-small cell lung cancer in patients with significant renal insufficiency?

In locally advanced EGFR-mutated NSCLC with initial good response to osimertinib, how do you manage local progression of the primary?

Would you consider SBRT and continue osimertinib?

Do the results of CheckMate 451 (nivo-ipi or nivo maintenance after chemotherapy in patients with SCLC) raise any questions for you about the role of immunotherapy in SCLC as established by the CASPIAN and IMpower 133 trials?

How do you approach a patient with discordant mutation testing in liquid vs tissue biopsy for mNSCLC?

For example, ALK+ in liquid platform, but negative on tissue biopsy.

How do you approach missed doses of durvalumab consolidation in patients with Stage III NSCLC?

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?

Do you recommend prophylactic cranial irradiation for ES-SCLC patients now that immunotherapy is included in the treatment schema?

If so, do you allow a period of "washout" between immunotherapy and radiation?

As consolidative thoracic radiation (cTRT) was prohibited on the seminal chemoimmunotherapy trials in ES-SCLC, how do you approach cTRT in practice?

Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...

How do you approach the treatment of patients with widespread ES-SCLC with a poor performance status?

How do you decide between supportive care v. chemoimmunotherapy? Is there a threshold of disease burden that would push you towards recommending hospi...

Is there a preferred ALK targeting agent for patients with ALK+ mNSCLC presenting with CNS metastases?

For patients with EGFR mutation positive NSCLC who progress on first line TKI without actionable resistance mechanisms, would you consider chemotherapy + targeted therapy as a second line option, or chemotherapy +/- immunotherapy?

Do you have any special diagnostic or treatment considerations when evaluating never-smokers with metastatic small cell lung cancer?

As SCLC in never smokers is extremely rare, do you consider NGS testing, or do you modify treatment in any way?

Would you send a lung cancer patient for genetic counseling/germline mutation testing if they are harboring mutations in NGS with variation allele frequency between >=50%?

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...

What second line treatment would you consider in patients with ES-SCLC with recurrence after front line chemo-immunotherapy?

What clinical factors do you take into consideration? Would you recommend chemo-immunotherapy regimens for a fit patient who relapses at 6 mos post-t...

Are there circumstances where you would recommend every 6 week dosing schedule for pembrolizumab monotherapy?

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 ...

Do the results and approval based on ADAURA trial suggest a role for adjuvant osimertinib in patients with stage IIIB-C, EGFR mutant patients treated with concurrent chemoradiation?

Should we consider radiation therapy for patients with N2 EGFRm NSCLC who will receive osimertinib, though RT was excluded on ADAURA?

Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?

How do you treat a patient with widely metastatic, non T790M mutated, EGFR exon 20 insertion mutated lung cancer?

Are there any data to support a specific TKI therapy for non-T790M exon 20 mutations/insertions?

Do you routinely check EGFR mutational status in all resected NSCLC regardless of histology?

Would you consider stopping maintenance immunotherapy for ES-SCLC after 2 years for exceptionally responding patients?

Would you differentiate between patients with measurable disease vs NED? Are there specific data to guide us?

Are there any data to guide choice of immunotherapy agent in first line treatment for extensive stage small cell lung cancer?

eg. chemo/durvalumab vs chemo/atezolizumab?

Does stage of resected EGFRm NSCLC impact your treatment decisions for use of adjuvant osimertinib?

What was the magnitude of benefit for patients with EGFRm NSCLC by stage? Are you still considering adjuvant osimertinib for patients with earl...

Assuming an absolute contraindication to immunotherapy and good PS, what is your preferred first line for metastatic squamous cell carcinoma of the lung?

For patients with RET-fusion+ NSCLC who progress on RET inhibitors, do you repeat tumor molecular profiling before selecting subsequent therapy?

If yes, do you re-biopsy for tissue, or perform blood-based sequencing?

Are you treating patients with RET-fusion+ metastatic NSCLC with RET inhibitors as the first line of therapy regardless of PD-L1 expression?

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

How do you approach a patient with good PS and no treatment contraindications who has progressed on a RET inhibitor for NSCLC?

Are you performing repeat molecular sequencing after progression on targeted therapy? If so, are you obtaining tissue biopsy vs liquid platform?

How do you manage end-organ toxicity such as hepatotoxicity or pulmonary toxicity in a patient receiving RET-inhibitors for NSCLC?

Are you ordering EGFR testing on all patients with NSCLC after complete resection in light of ADAURA?

If patients do recur, do you perform these tests on the initial surgical specimen or on tissue from a fresh biopsy (or both?)

How does the lack of mandated PET or brain MRI in the ADAURA trial impact your interpretation of the results?

Is data available regarding the percentages of patients in each arm who underwent staging PET or the breakdown of CNS imaging modalities?

Should 3 years of adjuvant osimertinib be the standard of care for resected Stage IB-IIIA EGFRm NSCLC?

How late after surgery would you consider prescribing osimertinib as adjuvant therapy in patients with resected EGFRm NSCLC?

How will the ADAURA study impact your use of adjuvant chemotherapy?

Are the rates of adjuvant chemotherapy used in ADAURA consistent with real-world practice?

When would you ever choose cisplatin over carboplatin in extensive stage small cell lung cancer?

Is it safe to continue capmatinib during palliative radiation to a bone lesion in patients with metastatic lung cancer?

How do you proceed with treatment of a patient with stage IIIB NSCLC who progresses DURING treatment with concurrent weekly carboplatin/paclitaxel and radiation?

Assuming no clinical trial, no actionable mutation, and PD-L1 < 50%, do you consider the patient to be primary refractory to platinum and move to s...

Would you consider treating a patient who has an unresectable slowly growing PET avid lung mass with concurrent chemo RT when multiple biopsy attempts have only resulted in pathology "suspicious" for adenocarcinoma of the lung?

When would you consider adjuvant chemotherapy for resected, intermediate grade lung neuroendocrine tumors?

Pathology is not carcinoid or small cell.

What is the optimal management of patients with stage II lung cancer without nodal metastasis, but unresectable due to poor pulmonary reserve?

For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?

Would you give immunotherapy to patient with metastatic NSCLC who had liver transplant for hepatocellular carcinoma and now is progressing on chemotherapy?

For patients with early stage resected giant cell lung cancer and other less common histologies, are there any specific considerations for adjuvant therapy?

How would you manage a patient with newly diagnosed locally advanced NSCLC and concurrent, active tuberculosis on anti-TB therapy?

After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...

For ALK positive NSCLC, where in treatment sequencing do you utilize lorlatinib?

Does the recent CROWN trial affect your first line treatment decision?

Would you continue durvalumab beyond 12 months in an oligometastatic NSCLC patient treated with concurrent CRT followed by consolidation durvalumab after treating a single metastatic site?

How would you approach therapy for a SMARCA4-deficient undifferentiated sarcoma with isolated involvement of a mediastinal lymph node?

No primary thoracic mass identified. Knowing these often following an aggressive clinical course, would you consider concurrent chemo/RT, incorporate ...

For patients with NSCLC with non-classical driver mutation alterations (atypical EGFR, BRAF nonV600E, etc), what resources do you utilize to determine likelihood that tumor will be sensitive to targeted therapies?

How do you approach patients with unresectable NSCLC planned for concurrent chemoradiation who develop a serious infusion reaction to paclitaxel?

What criteria do you use to select which patients with thoracic mesothelioma to send for an extrapleural pneumonectomy or pleurectomy/decortication?

How do you approach patients with stage III unresectable, combined histology NSCLC/SCLC?

Following chemoradiation, would you consider maintenance durvaluamb as for NSCLC even given the SCLC component?

Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

12 Answers available

What is your approach to patients who experience widespread progression on EGFR inhibitors found to have MET amplification on tumor biopsy in addition to sensitizing EGFR mutation?

Would you consider maintenance immunotherapy following chemoradiation for a patient with an isolated mediastinal recurrence of NSCLC?

For patients with metastatic thymic carcinoma, what would you offer patients who progress after platinum doublet chemotherapy?

How would you treat patient with a recurrent thymic carcinoma after prior surgery and concurrent chemoradiation?

Chemoradiation completed 1.5 years prior

How long would you wait after palliative short course radiation (i.e. 30Gy / 10 fractions) in metastatic NSCLC before initiation of chemo-immunotherapy?

How would you approach giving concurrent chemoradiation for Stage IIIB lung adenocarcinoma in the setting of concurrent Int-2 myelofibrosis which has been stable without cytopenias on ruxolitinib?

Would you modify the radiation dose or field in this setting? Would you pre-emptively dose reduce chemotherapy, or modify the dosing of ruxolitinib?

How would you approach a T1N1 NSCLC with a small peripheral primary tumor and single hilar node in a patient not fit for concurrent chemo or surgery?

Would you offer SBRT to both sites, SBRT to the primary and standard fractionation to the node due to proximity to the main bronchus/proximal lobar br...

Would you offer radiation alone to localized recurrence of extensive stage small cell lung cancer while on maintenance immunotherapy or would you start alternative systemic therapy?

Would it matter the site of recurrence (ie lung nodule vs bone lesion)?

How would you approach metastatic NSCLC (adenocarcinoma without brain mets) with PD-L1 >50% and BRAF V600E driver mutation?

Do you offer surveillance brain imaging for patients with EGFR+ NSCLC, stable systemic disease on TKI, and no history of metastatic brain disease?

Would you consider adjuvant chemotherapy for concurrent early stage NSCLC in ipsilateral separate lobes, or do you consider them as separate primaries?

Would you consider nivolumab and ipilimumab as first line for pleural mesothelioma?

Does the reported positive endpoint in OS for Checkmate 743 change your practice?

How would you treat oligometastatic NSCLC (brain and bone) with Non-V600E BRAF mutations?

SRS done to the single brain met, PD-L1 5%, BRAF G469A mutation

How would you treat a patient with metastatic NSCLC with repeated episodes of CNS brain metastases but otherwise with good systemic disease control on maintenance therapy?

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

When do you add chemotherapy to post-operative RT for thymomas after a R2 resection?

Is there still any role for afatinib (or first generation TKIs) in the management of EGFR mutated metastatic lung adenocarcinoma?

What is your standard approach for patients with platinum and ICI refractory small cell lung cancer?

Topotecan, nivolumab/ipilimumab and others are listed within NCCN guidelines, and lurbinectedin was recently approved in this space. How do you decide...

Would you assume a diagnosis of metastatic recurrence and initiate therapy for a patient with history of locally advanced NSCLC treated with definitive chemoradiation who develops multiple enlarging lung nodules that are too small to biopsy?

Is there an advantage to early diagnosis and intervention versus observation until the nodules are amenable to percutaneous biopsy?

Are there any safety or efficacy data regarding the use of EGFR inhibitors in patients on hemodialysis for ESRD?

Which criteria do you follow to recommend low-dose CT screening in patients at high risk for lung cancer?

The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?

Would you add bevacizumab to osimertinib for a patient with NSCLC who is progressing on osimertinib with no other actionable resistance mutations?

How soon after surgery do you start chemotherapy for extensive stage SCLC following resection of a brain metastasis?

How do you balance risk of chemo after surgery with risk of progression of disease while waiting for healing after surgery before starting chemo?

How do you treat extensive stage small cell lung cancer in the very elderly (more than 80 yrs)?

Should we be utilizing prophylactic G-CSF in our patients with intermediate risk of febrile neutropenia due to the COVID-19 pandemic?

Are you placing more weight on patient risk factors such as age >65 or co-morbidities?

Are you testing for PD-L1 IHC expression in extensive stage small cell lung cancer who are planned to be treated with chemotherapy plus immunotherapy?

Are there subsets of patients who will not benefit with addition of first line immunotherapy?

For patients with BRAF V600E positive lung cancer and recent PE/DVT, is there any contraindication to BRAF/MEK inhibitor therapy?

Would you hold treatment for patients who develop PE/DVT while on BRAF-directed therapy?

Does the final report and approval of CHECKMATE 227 (ipi/nivo) regimen change your first line recommendations for patients with PDL1 TPS < 1%?

With the approval of capmatinib, how would you approach a newly diagnosed metastatic NSCLC with MET Exon 14 skipping mutation?

Would you consider any form of 'maintenance' therapy for a patient in a CR2 following re-challenge with platinum doublet for small cell lung cancer after first line chemo-IO?

Since the approval of Carbo/VP-16/Atezolizumab (IMpower133) for extensive stage small cell lung cancer, how are you treating those patients who progress > 6 months after chemotherapy alone who were treated prior to the approval of IMpower133?

Would you treat with platinum-etoposide alone again, or would you add atezolizumab? IMpower133

Would you offer systemic therapy after rendered NED from SRS to isolated CNS metastases in a patient with prior curative intent treatment of lung adenocarcinoma and clear cell RCC?

How do you treat a patient with synchronous locally advanced lung and head and neck cancers?

Does the availability of first line checkpoint inhibitor therapy affect your treatment decision?

How would you treat an SCLC patient who manifests a bona fide etoposide allergy on cycle two day one?

Would you continue pembrolizumab in an asymptomatic metastatic NSCLC patient with high PD-L1, who develops granulomatous mediastinal lymphadenopathy biopsy proven as sarcoid?

How would you treat a patient with metastatic NSCLC on pembrolizumab with a sustained complete response, now with 2 isolated small liver lesions?

Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?

What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?

Would you withhold immunotherapy for ES-SCLC during the COVID-19 pandemic?

What are the risks of infection with COVID-19 if using immunotherapy?

How do you manage pneumonitis in patients with Stage III NSCLC receiving durvalumab?

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 any subsets of patients where you would consider first-line dacomitinib for EGFR mutations positive NSCLC?

Are there specific mutations or co-mutations were you would consider use of this agent?

Would you offer EGFR inhibitors to a patient with metastatic lung adenocarcinoma EGFR L858R mutation and concomitant NRAS mutation both on blood based testing?

What is the appropriate concurrent chemoradiation regimen to treat unresectable stage IIB lung adenocarcinoma?

Is there any role for immunotherapy?

How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?

Should staging and treatment decisions be made based on imaging alone?

How should you manage a coronavirus infected/suspected patient who is receiving radiotherapy and cannot interrupt or delay their cancer treatment?

How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...

7 Answers available

In patients with metastatic lung SCC who are on pembrolizumab maintenance after starting pembrolizumab/carboplatin/nab-paclitaxel, what is your treatment strategy if they progress while on pembrolizumab alone?

Would you continue pembrolizumab with a re-challenge with carboplatin/taxane or move to second line therapy?

Would you consider first line osimertinib to patients with an EGFR Exon 18 G719X mutation?

Are the specific Exon 18 mutations that are more sensitive to TKI?

Should we consider deferring adjuvant chemotherapy for resected early-stage NSCLC in light of COVID-19?

If so, how long is too long to wait?

What scenarios, if any, are you delaying adjuvant chemotherapy in light of the COVID-19 outbreak?

In which group of patients you would send for RNAseq for translocations/fusions that might be missed by NGS in advanced NSCLC?

For patients with metastatic adenocarcinoma of the lung, do you base any treatment decisions on EGFR gene amplification?

Many commercial testing assays report on EGFR gene amplification in addition to the known sensitizing mutations. Are there any data that this can be u...

How would you treat a patient with extensive-stage small cell carcinoma and severe end-stage COPD on home oxygen?

Would you treat with chemotherapy (carboplatin/etoposide) vs anti-pd-1 monotherapy vs combination chemoimmunotherapy vs supportive care?

How would you approach maintenance therapy following chemo-immunotherapy for extensive-stage small cell lung cancer per the IMPower133 trial if there is a mixed response post-treatment but clearly some clinical benefit?

Would you proceed with maintenance atezolizumab or switch to second line therapy?

How long do you give maintenance pemetrexed/pembrolizumab in metastatic NSCLC treated with upfront chemoimmunotherapy?

Do you ever consider stopping if stable disease and good tolerance?

Would you discontinue dabrafenib/trametinib in a patient with BRAF mutant metastatic lung cancer if you see mild cardiomyopathy which could be related to the drugs?

Patient does not want chemo but is tolerating these well otherwise.

Do you recommend routine dental evaluation for all patients before starting bisphosponates in patients with bone metastases?

Do you offer systemic therapy for NSCLC (no driver mutation) after resection of a metachronous solitary brain metastasis occuring after definitive therapy for limited disease, with no evidence of active extracranial disease?

For locally recurrent disease after surgical resection of EGFR/ALK positive NSCLC that appears suitable for chemoradiation, would you proceed directly to chemoradiation or consider TKI first?

Does timing of recurrence (early vs late) factor into your decision and would you consider consolidation durvalumab?

How do you approach treatment for solitary fibrous tumor with a multifocal pleural-based metastatic recurrence that is surgically inoperable in a patient with good performance status?

How, if any, do you utilize genomic testing to guide systemic therapy?

Would you treat a patients with metastatic squamous cell lung cancer with >/= 50% PDL-1 expression with first line pembrolizumab/carboplatin/paclitaxel combination or with pembrolizumab alone?

Keynote 407 recently published data on pembrolizumab +/- chemo for metastatic squamous cell lung cancer. The confidence interval for the group w...

In a patient with ILD and metastatic NSCLC with positive PD-L1, would you give chemo/pembrolizumab, chemotherapy alone, or pembrolizumab alone?

Does the degree of PD-L1 expression weigh into your decision?

How does your management change for patients with bone marrow failure due to a metastatic solid tumor to the marrow?

Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?

How would you approach a patient with metastatic squamous NSCLC that progressed on carbo/paclitaxel/pembro and has a FGFR3 S249C mutation?

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...

Should durvalumab consolidation still be offered to Stage III NSCLC patients with PD-L1< 1%?

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 an asymptomatic patient requires a delay up to a week before starting chemotherapy for Stage III lung cancer, do you also push back the radiation start date?

Our medical oncology team wants to give a patient Vitamin B12 and Folate 1 week before chemo- do we need to push back the RT start date to start both ...

How would you approach frontline treatment for a metastatic non-squamous NSCLC patient with MET amplification and a concurrent KRAS mutation?

How do you counsel patients with metastatic NSCLC who have a sustained response (> 2 years) to checkpoint inhibitors who wish to discontinue therapy?

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 ...

Do patients with Stage III unresectable NSCLC with lepidic features require a different approach to chemo-radiation?

Would your choice of concurrent chemotherapy be impacted by this histologic finding?

How do you treat a fit patient with a solitary pulmonary nodule (2cm) which is biopsy-proven small cell lung carcinoma?

PET-CT and Brain MRI are negative for other evidence of disease.

Would you consider checkpoint inhibitor therapy alone in a patient with metastatic NSCLC with PDL-1 < 1% who is otherwise refusing chemotherapy?

Would nivo + Ipi be appropriate in this situation, especially if high TMB?

For patients with a complete response to immunotherapy, or even durable partial response, should immunotherapy be continued until progression or recurrence or is there any data for stopping at a certain time point (i.e. two years)?

What is the role for "liquid biopsy" for patients with newly diagnosed metastatic NSCLC?

Especially in light of the new Guardant data presented at AACR 2019

Do you offer consolidative thoracic radiation for oligometastatic NSCLC following upfront immunotherapy?

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

Would you rather start radiation for Stage III NSCLC in the middle of a chemotherapy cycle or wait for the 2nd cycle if it could not be started on cycle 1 day 1?

How would you manage a patient with no driver mutation, PD-L1 <50%, with systemic relapse of lung adenocarcinoma within a year after resection and completion of adjuvant platinum based chemotherapy?

Would you consider single agent immunotherapy given recent exposure to platinum agent or chemoimmunotherapy?

How would you approach frontline treatment of a patient with metastatic non-squamous NSCLC with ERBB2 amplification and PD-L1 > 50%?

In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?

How do you approach patients for definitive chemoradiation in locally advanced NSCLC who have severe neuropathy?

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

How do you treat non-resectable carcinoid of the thymus?

Would you consider first line treatment with somatostatin analog or Lu 177 dotatate? Is observation an option for asymptomatic patients?

Are there data for treating patients with metastatic NSCLC with BRAF nonV600E mutations with BRAF and MEK inhibitors?

Are there any data regarding response to checkpoint inhibitors for these patients?

What treatment would you consider for ES-SCLC that is refractory to first-line platinum plus immunotherapy?

How would you treat a case of mixed histology NSCLC/SCLC that rapidly progresses following chemoradiation and durvalumab?

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...

How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?

Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...

How would you treat a metastatic lung adenocarcinoma with MET exon 14 skip mutation on ctDNA, negative tissue NGS and PD-L1 of >50%?

The NCCN guidelines regard MET exon 14 skip mutation as an emerging biomarker but no formal recommendation to start crizotinib. If high P...

Are PD-L1 and molecular markers from pleural fluid specimens reliable enough to guide decision making in metastatic NSCLC?

Or would you conduct tissue or blood testing if no actionable results are found?

What is your preferred induction chemotherapy for stage IIIA NSCLC squamous and adenocarcinoma?

Is there any advantage of one regimen over the others?

Would you offer WBRT to a patient with ES-SCLC with improving brain mets on immunotherapy?

Is there a role for upfront next generation sequencing in extensive stage small cell lung carcinoma?

For limited stage SCLC with curative intent, do you ever substitute carboplatin for cisplatin in concurrent CRT setting?

For metastatic large cell neuroendocrine carcinoma of lung, would you treat as small cell with platinum/etoposide/atezolizumab or would you treat as NSCLC and use platinum doublet/pembrolizumab?

Are EGFR exon 20 insertion mutations in lung cancer predictive of a poor response to immunotherapy?

Are you checking for any specific mutations in NSCLC that suggest resistance to checkpoint inhibitors?

Are there any biomarkers that would affect your decision for first line PD-1 therapy (including but not limited to STK11)?

How would you treat a patient with metastatic NSCLC >50% PDL-1 positive AND an EGFR or ALK gene mutation/rearrangement in the first-line setting?

1st-line pembrolizumab is supposed to be used AFTER failure of appropriate targeted agents in this setting, but would you consider the reverse sequenc...

How do you treat patients with stage III squamous cell carcinoma of the lung with persistent/progressive disease despite concurrent chemoradiation?

How would you utilize PD-L1 expression to guide your decision making in this situation?

How do you decide whether or not to give immunotherapy in patients with a history of an isolated, severe autoimmune event?

For instance, not chronic autoimmune diseases (eg RA, IBD) that may relapse/remit but events like Guillan Barre syndrome that is not likely to recur b...

How do you approach a patient who responded to first line osimertinib but develop an isolated progressing lesion that retains sensitizing EGFR mutation but develops MET amplification?

Would you continue osimertinib after radiation therapy, switch to crizotinib, or consider chemotherapy +/- immunotherapy?

Do you check baseline or surveillance audiometry (if not overtly symptomatic) to screen for hearing loss in all patients getting cisplatin?

How do you choose between atezolizumab, bevacizumab, carboplatin, paclitaxel (IMpower 150) vs. pembrolizumab plus chemotherapy (KEYNOTE 189) in patients with metastatic NSCLC?

How would you approach a patient with Stage III EGFR+ NSCLC who develops oligometastatic disease while on consolidation durvalumab?

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...

When considering adjuvant chemotherapy for resected lung cancer, do you treat rarer histologic patterns such as acinar or lepidic the same as you would a more typical NSCLC?

Is there a role for incorporating local therapy into the management of oligometastatic EGFR-mutant NSCLC with curative intent?

If so, what is your approach to sequencing and timing of targeted therapy and local therapy?

How do you approach adjuvant chemotherapy for high grade large cell neuroendocrine lung cancers?

Should these patients be managed using small cell lung regimens?

How do you decide between carboplatin vs not recommending adjuvant chemotherapy entirely for patients with resected NSCLC with relative or absolute contraindications to cisplatin?

ie renal dysfunction, hearing loss, neuropathy

What is your preferred first line therapy for ROS-1 rearranged metastatic NSCLC for patients presenting with CNS metastases?

What would you recommend as a first line systemic therapy for metastatic sarcomatoid carcinoma of the lung without driver mutations?

Would you deliver SRS/XRT for isolated asymptomatic CNS metastasis before start of immunotherapy for stage IV lung cancer (negative for driver mutation) with high positive PDL1?

Do you consider additional chemotherapy or durvalumab after definitive concurrent chemo/RT for Stage II NSCLC for patients who are not surgical candidates?

Would PDL-1 status impact your decision?

Do you consider initiating systemic therapy for patients with NSCLC who develop oligometastatic disease and have all known sites of disease treated with SBRT?

With the recent finding of benefit of pembrolizumab and SBRT (PMID: 31294749), would you consider "adjuvant" pembrolizumab for PDL1 positive patients?...

How do you approach elderly patients with stage III NSCLC who have a reasonable performance status?

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

Aside from MET exon 14 skip mutations, are there other targetable MET mutations or fusions that you would consider for TKI therapy?

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

For patients with EGFR-mutant NSCLC who progress on osimertinib, do you repeat tumor molecular profiling?

If so do you favor repeat tumor biopsy or cfDNA?

In patients with metastatic NSCLC with EGFR mutation currently being treated with osimertinib, would you consider increasing dose from 80mg to 160mg at the time of progression?

What if only site of progression was in the brain/CNS?

Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?

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

What is your approach for locoregional mediastinal recurrence of NSCLC adenocarcinoma in fit patients >5 years from definitive treatment (chemoradiation and/or surgery)?

Would this approach be different for a patient treated with tri-modality therapy (ie neoadjuvant chemoradiation followed by resection)?

Does Keynote 189 establish combination chemoimmunotherapy as the standard of care for Stage IV lung adenocarcinoma?

Given the prior results of Keynote 189, how do you plan to utilize the data from Keynote 042 with pembrolizumab monotherapy?

What would you recommend as a subsequent therapy for patients with ROS-1 gene re-arrangement after progression on crizotinib?

What is your routine workup and treatment approach to patients with NSCLC NOS discovered in mediastinal nodes but without obvious primary lung lesions or metastatic disease?

Would you consider using a targeted agent as induction therapy outside of clinical trial for a patient with stage IIIB (N2) who may be a candidate for surgical resection and has a targetable mutation?

Do you utilize consolidative radiation for metastatic NSCLC lung cancer patients on maintenance immunotherapy?

Or do you reserve in case of oligo-progression or progressive/symptomatic disease?

For a patient with unresectable EGFR positive lung adenocarcinoma treated with chemoradiation and a single site of oligometastasis treated definitively, would you consider durvalumab as per PACIFIC study or EGFR-direct therapy?

In the absence of specific driver mutations, are you routinely offering combination chemotherapy + immunotherapy first-line for metastatic squamous cell carcinoma of the lung in patients with autoimmune disease, but not currently on immunosuppression?

Would the presence of high-titer antiphospholipid antibodies (for example) in the absence of a clot history alter your decision?

For newly diagnosed ALK or EGFR + NSCLC with oligometastases to brain only and otherwise cN0-1 thoracic disease, would you offer alectinib/osimertinib alone or SRS to brain + concurrent chemoradiation/surgery to chest?

With the FDA approval of third line pembrolizumab for patients with SCLC, how would you select a candidate for pembrolizumab or nivolumab in the third line management of SCLC?

How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?

CT or PET? If so, how often?

What are your recommendations for holding bevacizumab before and after SBRT to the lung?

What is your preferred approach for stage III NSCLC with single station N2 disease amenable to lobectomy?

What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...

Does consolidation durvalumab increase the risk of pneumonitis in Stage III NSCLC?

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.

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?

How do you identify immunotherapy-related pneumonitis vs. radiation pneumonitis in a patient status post chemoradiation receiving consolidation immunotherapy?

Is IO related pneumonitis in the radiation field or more diffuse?

Has the recently published SELECT trial of adjuvant erlotinib in early stage EGFR-mutant NSCLC impacted your management of these patients?

SELECT trial

How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?

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...

In light of recent data suggesting limited activity of Atezolizumab monotherapy in the 2nd line treatment of ES-SCLC, would you still offer Atezolizumab maintenance following combination chemo-IO in the first line setting?

Based on new data from ASCO2019, would you consider gefitinib +chemotherapy instead of osimertinib frontline for EGFRm metastatic NSCLC pts?

http://abstracts.asco.org/239/AbstView_239_262655.html

What are the clear criteria for unresectability in locally advanced NSCLC patients, other than medical or anatomic?

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

How do you approach nodal coverage in PORT for NSCLC with involved station 8?

Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...

Would you ever consider offering more than 4 cycles of adjuvant chemotherapy in early stage NSCLC?

NCCN guidelines recommend adjuvant chemotherapy for patients with stage 2 or 3 R0 resected NSCLC including 4 cycles of platinum based chemotherapy, bu...

Would you extrapolate data from PACIFIC trial for unresectable disease to consider consolidation therapy with durvalumab for Stage III NSCLC with single-station N2 disease amenable to lobectomy?

In a germline BRCA2 positive pt with NSCLC after chemoIO frontline and taxotere as a second line, would you consider PARP inhibitors?

If so, would you combine them vs monotherapy? Patient ECOG is 1

What is your preferred third line treatment option for metastatic NSCLC after first line chemo-immunotherapy and second line single-agent chemo (assuming no actionable mutations)?

What is your approach to patients with severe infusion reaction but excellent response to checkpoint inhibitors?

Do you consider specific pre-medications, an alternate checkpoint inhibitor, or abandon ICI altogether?

Do you stop consolidative durvalumab after one year as per the PACIFIC trial or continue if the patient is otherwise tolerating well?

Would you offer the PACIFIC protocol to a patient with stage III lung cancer with performance status 2-3?

If so, how would you modify this regimen?

Have you changed your steroid pre-medication regimens when treating with chemo-immunotherapy combinations for metastatic NSCLC vs chemotherapy alone?

Retrospective studies (PMID: 29935305, PMID: 30125216) have shown a correlation between poorer outcome and baseline steroid use in patients treat...

How do you approach management of limited stage SCLC in a patient with idiopathic pulmonary fibrosis?

If you are treating a patient with palliative radiation for hemoptysis do you require chemotherapy to be held?

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

For stage III NSCLC treated with definitive intent chemoRT, how do you decide to proceed with surgery vs consolidation immunotherapy?

For small peripherally located NSCLC, when do consider referral for mediastinal evaluation prior to curative surgery vs proceeding to resection with mediastinal eval at time of surgery?

In otherwise stage III NSCLC patients with a single metastatic site that is treated definitively (radiation or resection) followed by standard of care chemoradiation, would you still consider consolidation immunotherapy?

What is the best supportive care for lacrimation/rhinorrhea with pemetrexed for lung cancer?

Do you typically recommend avoiding neupogen during radiation treatments?

After progression on osimertinib, do you recommend overlapping TKI with 2nd line chemotherapy to avoid accelerated disease progression?

Retrospective data suggest clinically significant disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung canc...

What would be your approach in a patient with MET amplification and PDL-1 80% expression?

Do you use crizotinib for first-line therapy?

Do we have any data on sequencing of up front therapies for patients with high PD-L1 and targeted mutations?

First line pembrolizumab is only approved after progression on TKI - but would you ever offer chemo-immunotherapy prior to target therapy?

How are you treating patients who progress while on durvalumab after definitive chemoradiation for stage III NSCLC?

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 patients with NSCLC with large primary tumors (ie T4) but no mediastinal nodal involvement who are found to have isolated oligometastatic disease in the brain, do you still consider definitive management of the primary lung tumor?

Do you consider MET amplification in your first-line treatment decisions for patients with metastatic NSCLC?

With the approval of frontline pembrolizumab monotherapy for advanced NSCLC with PD-L1 of 1% or above, how do you select who gets Chemo-IO versus pembro monotherapy if PD-L1 between 1-49%?

In patients who have pneumonitis related to ALK inhibitor therapy, is it possible to rechallenge patients with the same drug or a different ALK inhibitor?

Is there one drug that carries the least risk of pneumonitis?

Do you offer consolidation thoracic radiation after atezolizumab, carboplatin, and etoposide for extensive stage small cell lung cancer?

When do you consider employing the 4-week dosing schedule for nivolumab?

The FDA has approved the new dosing schedule of Nivolumab 480 mg every 4 weeks for multiple disease sites (melanoma, RCC, urothelial carcinoma, SCC of...

Are you offering durvalumab to patients with Stage III NSCLC with known targeted mutations (ie ALK, EGFR, ROS1, BRAF) after completion of chemoradiation per PACIFIC?

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...

How do you approach patients who progress on maintenance atezolizumab after platinum based chemotherapy for extensive stage small cell lung cancer?

How do you time same-day chemotherapy and radiation for patients undergoing concurrent chemoRT?

For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...

For metastatic NSCLC patients with mixed response to pembrolizumab, would you radiate focal progressing lesions and continue pembrolizumab, add in chemotherapy to pembrolizumab, or discontinue pembrolizumab and move to second line?

How do you treat patients with sensitizing EGFR mutations who progress on osimertinib with small cell transformation, but with persistent EGFR mutation detected in the peripheral blood or tumor?

Is there a role for attempting to continue EGFR inhibition in addition to chemotherapy for small cell lung cancer?

Would you consider adding atezolizumab to a different chemotherapy/platinum-doublet backbone from the IMpower 133 trial for a new ES-SCLC patient?

Would you consider adding atezolizumab to a cisplatin/irinotecan regimen, or cisplatin instead of carboplatin?

Would you trial a different TKI (vs chemotherapy) if a patient with metastatic EGFRm lung adenocarcinoma developed grade 4 pneumonitis on first line osimertinib?

When do you recommend broader molecular testing for clinical trials in stage IV NSCLC patients who have negative initial molecular testing for FDA-approved targetable mutations?

Would you resume durvalumab after several month hiatus due to IO unrelated medical comorbidities that has since resolved?

If it is still within the 12 month period and no disease recurrence?

How would you treat a patient with EGFR+ oligo-metastatic lung adenocarcinoma status post resection of the primary and metastatic sites?

Would you give adjuvant chemotherapy or start osimertinib?

Is it safe to deliver SBRT to progressive lung metastases to patients with metastatic RCC receiving concurrent pazopanib?

For patients with metastatic poorly differentiated large cell neuroendocrine carcinoma of the lung, do you typically use NSCLC or SCLC regimens?

Do you offer pembrolizumab monotherapy or carbo-pemetrexed-pembrolizumab to a patient with Stage IV large cell NSCLC with PD-L1 of 80% and KRAS+STK11 mutation?

Some retrospective data reports that STK11 (AKA LKB1) makes NSCLC resistant to immunotherapy.

How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?

No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.

What is your preferred chemotherapy regimen to give concurrently with radiation for unresectable stage 3 NSCLC?

What factors do you use to decide between weekly low-dose carboplatin and paclitaxel combination vs cisplatin based doublet, and do you routinelt...

For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?

There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...

What is your approach to asymptomatic patients with progressing lung metastatic adenoid cystic carcinoma originally arising from the trachea?

Do you routinely perform molecular testing?

What is your preferred third line approach for a patient with refractory small cell lung cancer who has failed second line therapy with nivolumab after recieving first line platinum based therapy ?

Would you offer immunotherapy combination (nivo/ipi) in patients who have failed nivolumab mono-therapy?

What are your recommendation for vaccines in patients while on immunotherapy?

Do you recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?

Would you still offer durvalumab after chemoradiation in patients with stage III NSCLC whose treatment was delayed due to prolonged recovery from chemoradiation?

At what point (ie 8, 10, 12 weeks or more) would you no longer offer consolidation durvalumab?

How do you decide between enrolling an oligometastatic NSCLC patient on LU-002 versus treating them with SBRT off trial?

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 ...

Do you offer adjuvant chemotherapy and/or radiotherapy for patients with resected atypical carcinoid of the lung with positive mediastinal lymph nodes (T3N2M0)?

Would you offer upfront osimertinib rather than whole brain irradiation for a patient with stage IV, EGFR exon 19 mutated lung adenocarcinoma who presents with leptomeningeal metastases?

Would you re-challenge patients with an EGFR TKI beyond progression if repeated biopsies show redemostration of a sensitizing mutation (exon 19 deletion) and no other resistance mechanisms?

How do you chose between 4 or 6 cycles of chemotherapy in patients with small cell lung cancer?

Does your practice differ based on limited or extensive stage disease?

Should radiotherapy be utilized in stage IVA NSCLC with a malignant pericardial effusion?

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

Do you still consider surgery for N2 NSCLC in the era of consolidative immunotherapy?

The NCCN guidelines suggest surgery can be considered for up to T3N2 NSCLC after a period of induction chemotherapy/chemo-radiation without progressio...

What first line treatment would you choose for stage IV adenocarcinoma of lung with ALK gene rearrangement and PD-L1 TPS 95%?

Should local consolidative therapy be offered to patients with oligometastatic NSCLC who do not progress after induction systemic therapy?

Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...

How do you discern between pseudo-progression or hyper-progression in patients with NSCLC or cancers treated with immune checkpoint inhibitors?

How common is hyperprogresion, and are there any strategies to mitigate it?

Is there a role for checkpoint inhibition in patients with advanced, high PD-L1 expressing, chemotherapy-refractory thymoma?

What if the patient has thymoma-associated myasthenia gravis?

For oligometastatic NSCLC that would be otherwise considered stage 3, would you consider consolidative immunotherapy with durvalumab after definitive treatment for both the primary and oligometastatic site?

What would you choose as the second line treatment option for a stage IV EGFR mutant lung adenocarcinoma that has progressed on osimertinib?

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

Would you use immunotherapy in a patient with metastatic lung adencoarcinoma, high PDL1, but had polymyositis as a presenting paraneoplastic syndrome?

Would you offer Durvalumab as consolidation therapy to a patient with stage III NSCLC but had local recurrence treated with definitive SBRT?

Prior to the PACIFIC trial, patients were treated with definitive chemo/rads. With local recurrence <1yr after chemorads and definitive treatment f...

Should atezolizumab be used with chemotherapy in the first line treatment of ES-SCLC?

Has the publication of IMpower133 changed standard of care?

Would you offer adjuvant chemotherapy to a patient with T3N0M0 NSCLC if the reason for the T3 stage was due to multiple tumor nodules in the same lobe?

All tumors in this case were <2cm in size.

What is the role of upfront pembrolizumab in metastatic PD-L1 positive NSCLC presenting with SVC syndrome?

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

Would you offer immunotherapy after chemoradiotherapy for Stage III lung cancer given results of PACIFIC Trial?

If so how would you select patients (ie. PS, histology, PD-L1 expression level)?

Is there a role for temozolomide in patients with Stage IV NSCLC with leptomeningeal disease who have progressed on first line chemo-immunotherapy?

Would you consider the use of intrathecal chemotherapy in patients with diffuse spinal metastasis due to squamous cell lung cancer?

How do you manage a patient with multiple similar appearing ground glass opacities (~8-9) on Chest CT where one has been surgically removed and confirmed to be adenocarcinoma in situ?

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...

What would be your next line of treatment for NSCLC adenocarcinoma that has recurred after chemoradiation with cis/etoposide?

PD-L1 < 50% and no targetable mutations. Would you use carbo/pemetrexed/pembrolizumab or Nivolumab or pembrolizumab?

Do you ever recommend PORT or chemoRT rather than chemotherapy alone for NSCLC with adverse features other than positive margins or N2 disease?

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

How do you manage a patient with decreased but residual PET activity following concurrent chemoRT and PCI for limited stage SCLC?

Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...

How would you approach a locally recurrent, unresectable (due to COPD) NSCLC that is ROS1 positive?

Would you treat with localized therapy with chemoradiation or SBRT or consider ROS-1 directed therapies?

What routine labs do you follow on patients on immunotherapy and how often are you checking them?

Are you routinely checking pituitary axis labs or any others in addition to thyroid labs?

Would you consider 160 mg of Osimertinib as opposed to 80 mg for adenocarcinoma lung with leptomeningeal metastasis?

What imaging surveillance do you do after SABR of oligo lung metastases?

Would you use the same schedule as early stage NSCLC primary?

When do you consider preoperative chemoRT v. chemotherapy in unresectable thymoma or thymic carcinoma?

The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...

How would you treat metastatic NSCLC in a non-smoker with bone biopsy showing adenocarcinoma of lung origin but inadequate tissue for mutational panel or PD-L1?

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 ...

How would you approach the treatment of resectable NSCLC with a solitary resectable brain metastasis and no other sites of metastasis?

Would you offer adjuvant therapy post resection?

For patients doing well on targeted therapies (alectinib, osimertinib) for metastatic NSCLC, what data / guidelines do you use to decide about holding treatment before/after surgical procedures?

Would you consider using a PD-L1 inhibitor after progression on a PD-1 inhibitor for metastatic NSCLC?

How would you treat a patient with emergence of EGFR C797S mutation at the time of progression on osimertinib given for EGFR T790M mutation?

Would your choice of treatment change if the same patient was T790M negative and osimertinib was given as a first-line therapy?

What is your preferred first line approach to patients with good PS stage IV non-squamous NSCLC that is EGFR/ROS1/ALK/BRAF WT and PDL-1 < 1%?

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

Is carboplatin/pemetrexed as effective as cisplatin/pem in treatment of unresectable malignant pleural mesothelioma in a patient with contraindication to cisplatin?

What is your preferred first line therapy for advanced NSCLC with an EGFR activating mutation?

Does the more recent NEJ026 trial describing benefit from Bevacizumab plus Erlotinib over Erlotinib alone in patients with EGFR driver mutations ...

Is it safe and/or necessary to combine osimertinib and carboplatin/paclixel for a patient with stage IV EGFR mutated NSCLC and advanced ovarian carcinoma?

Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...

How long do you continue low dose CT screening for lung cancer?

If there are 3 negative scans, do you continue annual screening?

Is there a role for prophylactic cranial irradiation in patients with NSCLC?

A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...

In which patients with stage IV NSCLC and PD-L1 TPS >50% plus concomitant autoimmune disease is it considered safe to give immune checkpoint blockers?

What is your current preferred approach in the management of metasatic sarcomatoid NSCLC?

Specifically, would carbo-taxol-bev-atezo (IMpower 150) be an attractive option given the activity of bev-atezo in sarcomatoid PDL1+ metastatic RCC (I...

What is the role of "adjuvant" systemic chemotherapy in patients previously resected NSCLC, now with isolated solitary relapsed brain lesion, treated with resection and SBRT?

Is there any data for the benefit for systemic chemo in such situation?

Is there any benefit to adding bevacizumab to chemo-immunotherapy in metastatic NSCLC?

For the Impower 150 trial, is there data reported on PFS and OS for ABCP vs ACP (atezolizumab/bevacizumab/carboplatin/paclitaxel vs atezolizumab/carbo...

Would you ever start radiation in the middle of cycle 1 of chemotherapy for LS-SCLC?

Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...

Would you consider first line therapy with PD-1 inhibitors (+/- CTLA4) for patients with metastatic NSCLC with high tumor mutational burden despite negative PD-L1?

How do you interpret the results of Checkmate 227 in light of Keynote 189 and Keynote 407?

Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

8 Answers available

Is pembrolizumab-carboplatin-pemetrexed an acceptable initial therapy for metastatic non-squamous NSCLC regardless of PD-L1 status?

Does the recent FDA approval based on PFS and response rate in KEYNOTE-021 warrant it's use?

How do you approach a lung malignancy with a single pleural nodule near a primary?

By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...

What factors might influence your initial treatment decision of oligometastatic NSCLC assuming good performance status, lack of actionable mutation, and PD-L1 status < 50%?

Would you consider "aggressive" concurrent chemoradiation followed by SRS to the CNS lesion and possible consolidative immunotherpay (the PACIFIC...

Have you used immunotherapy for NSCLC in a patient with multiple sclerosis?

Would you consider MS an absolute contraindication to this treatment?

Are there subsets of patient in which you would choose chemotherapy+pembrolizumab vs pembrolizumab monotherapy in metastatic NSCLC?

Given the results of Keynote 189, is there any benefit of chemotherapy+pembrolizumab in specific subsets of patients in the first line setting?

How would you approach patients with ALK-positive metastatic NSCLC who progress on crizotinib and subsequently alectinib?

In the absence of clinical trial, is there are role for dose-escalating alectinib, or would you consider brigatinib or chemotherapy?

How do you decide on the sequence of systemic and local therapy for patients with oligometastatic NSCLC?

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

Would you treat a patient with HIV or hepatitis C with an anti-PD-1 agent?

These patients have been largely excluded from these trials. What if the infection is well controlled?

Aside from radiation (WBRT or SRS), what is your approach to patients with EGFR-mutated or ALK-translocated metastatic NSCLC who have systemic disease control but fail in the CNS?

Do you increase dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discerete brain...

Can patients on steroids receive immunotherapy?

Assuming it is clinically indicated, would a checkpoint inhibitor be efficacious in a patient who has a concurrent autoimmune illness (PMR/TA) and is ...

Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?

Would you ever considering re-starting immunotherapy before completing the taper? According to the new guildelines on managing immunotherapy related ...

When do you recommend induction chemotherapy prior to concurrent chemoradiotherapy for locally advanced NSCLC?

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 other than resection status (R1,2) do you consider when offering adjuvant chemotherapy for patients with thymic carcinoma, and how do you coordinate with post-op radiation?

Do you use oral etoposide in combination with carboplatin for small cell lung cancer, in light of the national shortage of IV etoposide?

If so, what would be the regimen?

Do you recommend concurrent or sequential radiation and chemotherapy for margin-positive, node negative NSCLC?

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

Beyond PD-L1, when would you consider additional molecular testing (EGFR, ALK1, ROS1) for patients with squamous cell lung cancers?

Among the many assays/tests available for "liquid biopsies" in metastatic NSCLC, are there any situations where you would want to use one specific assay over the others?

What treatment would you offer for patients with metastatic NSCLC (adenocarcinoma) who are EGFR positive AND PD-L1 >50%, who fail first line EGFR therapy (and are negative for T790M mutation)?

Would you consider second line immunotherapy before considering chemotherapy?

Do you have a cut-off for bilirubin for treatment of patients with poorly differentiated NSCLC with good PS and liver dysfunction due to mets?

What regimen do you prefer?

How would you approach patients with EGFR mutation positive (exon 19) NSCLC who rapidly progress on front line EGFR inhibition with first generation TKI at first imaging?

Can T790M mutation develop within this early time frame, or are these perhaps patients who may benefit from switch to chemotherapy?

Should NSCLC with positive cervical nodes be managed with definitive chemoradiation?

Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?

Is there a role in sending liquid biopsy for patients progressing on ALK inhibitors?

In patients with T790M mutation and progression of disease on osimertinib, is there any utility in checking peripheral blood cDNA for continued presence or absence of the T790M mutation?

How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?

Are you using ctDNA blood tests for targetable mutations at the time of diagnosis, at the time of disease progression, or not at all?

Can ctDNA be used to evaluate response to checkpoint inhibitors in NSCLC when pseudoprogression is suspected on CT imaging?

Is there any role for ctDNA testing after surgery or SBRT for Stage IB NSCLC to determine the need for adjuvant chemotherapy?

What is the appropriate treatment approach for a primary squamous cell carcinoma of the trachea?

How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...

For NSCLC patients with limited diagnostic tissue that is insufficient for genetic testing, do you offer repeat biopsy (of accessible site), blood based testing, or both to evaluate for actionable driver mutations?

Based on the FLAURA trial, would you consider using osimertinib firstline in EGFR-mutated NSCLC?

In a patient with resected NSCLC whose only site of relapse is CNS (treated with WBRT or SBRT), would you also start systemic therapy with erlotinib/afatinib if the patient was found to be EGFR positive?

How are you incorporating abscopal radiation into your practice for metastatic NSCLC?

What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...

What is your preferred front line regimen for metastatic squamous cell NSCLC that is PD-L1 and driver mutation negative?

How do you select between the available treatment options (gemcitabine, docetaxel, paclitaxel, nab-paclitaxel) in combination with platinum? Up...

How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?

When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...

What is your next step in management for a patient with immunotherapy induced pneumonitis that does not improve on high dose steroids for 48 hours?

How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...

How do you sequence therapy for metastatic NSCLC patient with a BRAF V600E mutation?

Has the recent FDA approval of dabrafenib/trametinib changed your practice?

For untreated patients with minimal complaints and good PS with metastatic adenocarcinoma positive for Exon 21 L858R mutation, how do you choose among the available first line EGFR directed therapies?

Have the results of LUX-Lung 7 changed your routine practice? Are there promising up-front clinical trials that these patients may benefit from?

What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?

Do you incoprate Ki67% or mitotic rate into your treatment decision, and is there any use for somatostatin based imaging such as octreoscan or gallium...

Do you use a TKI for resected EGFR+ non-small cell lung cancer?

In IB-IIIA cases?

For ALK+ patients rendered NED from oligometastatic NSCLC after resection of both lung primary and isolated CNS lesion, do you consider offering treatment with an ALK inhibitor after adjuvant chemotherapy, or do you place into surveillance?

Is there any role for a trageted agent with CNS penetration (such as second generation ALK inhibitors) after completion of postoperative brain radiati...

With the accelerated approval of Brigatinib, and now three approved ALK inhibitors in the 2nd-line setting, how do you decide between these agents?

Should we be routinely sequencing ALK to select an ALK inhibitor with the appropriate efficacy, matched to resistance patterns?

Is there evidence of clinical benefit to proceeding with partial pleurectomy / decortication over palliative chemotherapy with BSC (pleurex catheter, pleurodesis) in a patient with mesothelioma who is not a candidate for extra-pleural pneumectomy?

What factors influence your decisions to offer neoadjuvant chemotherapy?

How many cycles of post-operative adjuvant chemotherapy do you typically plan for a patient with resected mesothelioma?

Is there any role for either the addition of bevaciziumab or for maintanance pemetrexed?

When would you consider local ablative therapy (e.g. SBRT, surgery) for patients with oligometastatic non small cell lung cancer on immunotherapy?

For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well.

Are certain PD-L1 assays considered more accurate or reliable than others for NSCLC?

How do the different assays compare when choosing a specific immunotherapy, and does this change for first vs second (or beyond) line of therapy?

When do you offer consolidation chemotherapy for patients receiving chemoradiation for locally advanced NSCLC?

How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?

Do you offer memantine for patients undergoing PCI?

How do you manage immune-related toxicity from checkpoint inhibitors that is refractory to initial steroid therapy?

What immunosuppressive agents are used and in what order? Does your approach differ depending on the organ involved, e.g. colitis vs. pneumoniti...

How would you manage a patient with surgically resected T3N1 NSCLC who is found to have one small brain metastasis on staging MRI?

In addition to addresing the brain met (surgery vs. SBRT), would you proceed with systemic "adjuvant" chemotherapy, or would you treat the patient as ...

In patients with metastatic NSCLC, would you consider atezolizumab after failure of nivolumab or pembrolizumab?

Is there any data to support this approach? If not, are there trials you are aware of looking at "rescuing" these patients with a different chec...

Would you continue immune checkpoint inhibitor therapy in a metastatic NSCLC patient with CNS failure if the systemic disease is otherwise controlled?

Does the extent/duration of systemic disease control (complete response vs. stable disease, for example) influence your decision? What about whe...

Do you ever consider referring fit patients with NSCLC and oligometastatic disease isolated to the pleura for extrapleural pneumonectomy?

Would you use immune checkpoint inhibitors in patients with well-compensated liver cirrhosis?

Does the risk of severe inflammation of the liver lead you to choose other therapies in in this population? What about in patients with mild liv...

For the rare NSCLC patient who achieves a CR on anti-PD-1 or PD-L1 therapy, do you consider either spacing out dosing intervals or offering treatment breaks?

How would you approach the management of a patient with oligometastatic NSCLC characterized by a LUL mass and a solitary adrenal metastasis, assuming a good performance status?

For patients with malignant mesothelioma who achieve macroscopic complete resection, what factors would lead you to consider adjuvant chemotherapy or radiation?

Does the presence of a sarcomatoid component influence this decision?

How do you manage hematologic toxicities in solid tumor patients treated with immune checkpoint inhibitors?

If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?

For patients with metastatic NSCLC with sensitizing EGFR mutations who progress on first line TKI therapy who do not have evidence of T790M mutation, do you add cetuximab (with afatinib) or bevacizumab (with erlotinib) at progression?

Based on JO25567 and the phase Ib trial of afatinib and cetuximab, for patients otherwise tolerating therapy would you consider adding these agents or...

When do you consider using ALK targeted systemic therapy in lieu of WBRT or SRS for patients with metastatic ALK-positive NSCLC?

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.

Do you use anti-PD-1/anti-PD-L1 therapies in lung cancer patients with a prior history of radiation pneumonitis?

What about patients who are still on steroids for radiation pneumonitis?

How would you approach a patient with biopsy-proven extrapulmonary small cell carcinoma (CT chest negative), characterized only by inguinal lymphadenopathy, who is otherwise asymptomatic?

If PET/CT is unrevealing for a primary source, would you treat such a patient with platinum-etoposide or monitor closely until further disease progres...

When patients with EGFR-mutant or ALK-translocated advanced NSCLC progress after all available targeted therapies, do you use chemotherapy or PD-1/PD-L1 inhibitor therapy as the next line?

Does recent data from the OAK study showing a survival benefit for atezolizumab over docetaxel even in non-smokers affect your decision making?

For lung cancer patients who experience grade 3/4 toxicity from a PD-1 inhibitor necessitating cessation of therapy, but whose tumor has responded to the treatment, do you consider restarting PD-1 inhibitor therapy at the time when they progress again?

Would you consider giving the therapy with concominant steroids, or with a dose reduction?

For the first-line treatment of metastatic lung adenocarcinoma without a targetable driver mutation, do you routinely add bevacizumab to the chemotherapy backbone in the absence of a contraindication to the drug?

Do you add bevacizumab regardless of whether you are using paclitaxel or pemetrexed with the platinum agent?

Are there any subgroups of patients with advanced/metastatic NSCLC for whom you are using PD-1 inhibitors in the first-line setting, either alone or in combination with platinum-based chemotherapy?

Also, are you testing for PD-L1 routinely prior to initiation of first-line systemic therapy?

How do you treat patients with small cell lung cancer that is primarily refractory to platinum/etoposide (i.e. disease that continues to progress despite first-line chemotherapy?)

For fit patients, what regimen do you prefer outside of a clinical trial?

For patients with advanced NSCLC who have radiographic disease progression on their follow-up scan after starting a PD-1 inhibitor, what characteristics (either clinical or radiographic) do you use to determine whether to continue with therapy or switch to something else?

I ask this question recognizing there is no great data here, and that "pseudo-progression" is rare, but I am looking for any guidance with regard to h...

For metastatic NSCLC patients who are started on first-line platinum doublet chemotherapy and are subsequently found to have an EGFR exon 19 or 21 driver mutation, do you switch to an EGFR TKI immediately once the mutation is detected or do you wait until progression on chemotherapy?

Do you offer the addition of necitumumab to first-line chemotherapy for patients with advanced/metastatic squamous cell NSCLC?

For a patient with stage III NSCLC who is treated with chemoradiation followed by surgery, when do you offer additional "adjuvant" chemotherapy after surgery?

Are you routinely offering nivolumab for second-line treatment of small cell lung cancer?

Based on recently published data from CheckMate 032, do you now offer nivolumab to small cell patients who have progressed after first-line chemothera...

When treating patients with immune checkpoint inhibitors, do you routinely check markers of endocrinopathies (i.e. TSH and ACTH) or only when a patient has symptoms?

If so, how often do you check these labs?

Do you use immune checkpoint inhibitors in NSCLC patients with pre-existing, well-controlled autoimmune disease?

Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?

In newly diagnosed metastatic non-squamous NSCLC patients, which (if any) genomic targets are you routinely testing for besides EGFR and ALK?

What about specifically in never-smokers?

Do you ever offer adjuvant chemotherapy to patients with resected stage IB non-small cell lung cancer when the tumor is less than 4cm in size?

4cm has historically been used as the cutpoint for determining benefit from adjuvant chemotherapy in this population (Strauss et al, JCO 2008; Bu...

Is there a role for VeriStrat testing in determining when to use an EGFR TKI in previously treated squamous cell NSCLC?

Although PD-1 inhibitors are now standard of care for second-line therapy of advanced NSCLC, there remains the question of which therapy is best to us...

Would you offer adjuvant TKI to patients with Stage III, EGFR-mutant NSCLC after standard chemoradiation?

Would you offer adjuvant TKI following ADAURA data? Or proceed with durvalumab based on PACIFIC data?

For T1b or T2a NSCLC cancer, approached with SABR, should chemotherapy be considered in the adjuvant setting?

As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?

Is there a role for post-treatment PET/CT following chemoRT for Stage III NSCLC?

The NCCN guidelines discourage the use of PET/CT surveillence but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...

Should the incorporation of thoracic RT be standard in patients with extensive stage small cell lung cancer?

Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...

How long do you continue maintenance chemotherapy for metastatic non-small cell lung cancer in patients who have achieved a radiographic CR?

Other than part of a clinical trial or for its FDA-approved indication (second-line therapy for metastatic squamous-cell NSCLC), when do you offer nivolumab to your patients with NSCLC?

For example, should nivolumab be considered standard second-line therapy for adenocarcinoma patients? Can it be considered for first-line thera...

What is the best adjuvant treatment for resected NSCLC?

Can chemotherapy be used instead of radiation therapy in a patient with extensive stage small cell lung cancer who presents with epidural spinal cord compression?

I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...

When do you give treatment breaks for patients with NSCLC undergoing chemoradiation with serious toxicity?

Would you treat a patient with small cell lung cancer (limited to lung and mediastinum) but also with a malignant pleural effusion with upfront definitive thoracic chemoradiation?

If so, what would you include in the target and what dose?

Is there a role for post-operative chemoradiation therapy in fully resected, margin-negative T3N1 NSCLC?

What mutational testing is considered the standard of care for NSCLC?

Should mutations other then EGFR and ALK be routinely tested for? Should next generation sequencing be routinely done?

How would you manage a patient with EGFR mutant adenocarcinoma of the lung on erlotinib with a single site of disease progression, but otherwise well-controlled disease?

Would you stop the Tarceva at this point?

Is it safe to give thoracic irradiation to a patient with lung cancer previously treated with a VEGF inhibitor?

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...