Non-small cell lung cancer   

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

What specific platforms do you use, individual biomarker/PD-L1 status vs NGS, tissue vs liquid or both? Must you wait for PD-L1 testing if mutation t...

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

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

Are there data for using checkpoint inhibitors in this setting? 

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

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

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

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

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

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

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

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

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

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

What is your general rationale for selecting from available options?

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

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

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

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

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

Does the site of treatment factor into your decision? 

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

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

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

Such as dysgeusia, headache, rash, fatigue, etc

Would you consider SBRT and continue osimertinib?

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

Do you aim to give a total of 26 doses or do you stop at one year from first dose no matter how many were given?

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

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

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

How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...

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

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

If so, how long is too long to wait?

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

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

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

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

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

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

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

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

 ie renal dysfunction, hearing loss, neuropathy

Would PDL-1 status impact your decision?

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

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

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

CT or PET? If so, how often?

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

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

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

If so, how would you modify this regimen?

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

Do you use crizotinib for first-line therapy?

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

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

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

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

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

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

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

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

Does the T stage or location of malignancy affect your decision?

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

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

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

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

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

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

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

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

Does this vary based on whether the patient had a lobectomy v. wedge resection?

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

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

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

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

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

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

What dose and fractionation would you consider if surgery is not an option? 

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

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

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

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

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

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

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

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

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

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

Or would you rather treat with 3D-CRT in order to initiate chemoRT concurrently?

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

In IB-IIIA cases?

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