Session Content References

COVID-19 rapidly affected our lives and the life of our patients. Vaccination campaign started one year ago. At least four types of vaccines are widely used in the US (Pfizer, Moderna, Johnson and Johnson and AstraZeneca). We will review the data in the general population and available data in the cancer population. In general, the activity of the vaccines are similar for patients with solid tumors and the normal population. Possible influencing factor are chemotherapy, use of steroids and age. Data on larger cohort of patients with lung cancer are lacking.

COVID-19 has had an impact on our lives but most of all on the lives of our patients. COVID-19 mortality in patients with thoracic neoplasms is over 30%. Vaccines have greatly reduced the percentage of symptomatic cases. The data in patients with solid tumors show that they have a similar efficacy to the normal population. There is little data on lung cancer.

• It is important to create awareness among patients and healthcare workers on the importance of vaccination, side effects and updates in efficacy.
• Attendees need to determine when and how the latest science will affect their day-to-day practice, and thus be able to narrow competency gaps across vaccines.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Potential Challenge/Barrier to Change:

Although vaccines are widely available, still a huge part of the population and of lung cancer patients are not vaccinated yet. There is a general fear and skepticism for the vaccination. It is important to create education and awareness of the subject among healthcare workers and patients.

This panel session will present some challenging cases in lung cancer which will be followed by dialogue amongst experts. Hopefully the dialogue will extend to audience participants to share their practice, philosophy and/or experience with others.

This session entitled “Challenging Cases in the Clinic” is intended to present complex cases in patients with lung cancer. The cases may be more complex that what is provided in typical guidelines. We intend to stimulate discussion and provide expert opinions on both diagnostic and management strategies.

• The management of patients with lung cancer is rapidly becoming more complex. A thorough understanding of the patient’s history, physical exam and diagnostic workup is critical to their management.
• The challenging cases presented may be outside of typical management guidelines. Complex decision regarding their management will require an understanding of the literature and how to apply its principles to some complex cases.
• These cases demonstrate the need for multidisciplinary care.

References:

1. Felip et al. Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small cell lung cancer (IMpower010): a randomised, multi-centre, open-label, phase 3 trial. The Lancet 2021 
2. Wu et al. Osimertinib in Resected EGFR-Mutated Non-Small Cell Lung Cancer. NEJM 2020.
3. Palma, DA et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomized, phase 2, open-label trial. Lancet 2019; 393(10185):2051-2058.
4. Albain KS et al. Radiotherapy plus chemotherapy with or without surgical resection for Stage III non-small cell lung cancer. Lancet 2009; 374(9687): 379-386.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

1. Understand the principles guiding the management of lung cancer patients.
2. Apply the scientific literature to the management of the cases reviewed.
3. Take home some expert opinions on the management of some challenging cases in lung cancer.

Potential Challenges/Barriers to Change:

1. Insurance authorizations for SBRT or molecular profiling
2. Challenges with multiple sequential NGS testing in different timepoints (ie. costs, logistics, turn-around time).
3. Many ‘Challenging Cases’ benefit from multi-disciplinary care opinions, due to complexity, lack of data, etc. How do we foster multi-D discussions in busy practices?

Attendees will be provided with educational tools to narrow knowledge gaps with regards the use of biomarkers to optimize patient selection for cancer immunotherapy. In addition, this learning session will discuss current knowledge regarding the efficacy and rationale for complex surgical- and radio-immunotherapy combinations. Attendees will be better able to identify at-risk patients for immunotherapy toxicity and render informed decisions regarding risk assessment for drug rechallenge in day-to-day practice.

Immunotherapy, including monoclonal antibodies targeting the immune checkpoints PD-1, PD-L1 and CTLA-4, have revolutionized the treatment of a growing list of cancers over the past decade. The expanded application of cancer immunotherapy and the use of these agents in complex multimodality and multi-drug settings has introduced significant clinical challenges. Identifying biomarkers that predict efficacy of PD-1 or PD-L1 inhibitors, understanding the role of radiation and surgery in cancer immunotherapy and the optimal agent dose, sequence and timing in the context of these multi-modal therapies represent recent advances in this field. In addition, characterizing the at-risk patients for immunotherapy toxicity as well as the safety of drug rechallenge in certain patient populations following a toxicity event are critical and ongoing sources of study. Staying informed is imperative to successful management of patients in this rapidly evolving field.

• Knowledge: The use of immunotherapy in the management of patients with cancer is a rapidly evolving field. Optimal management of these patients requires a multidisciplinary effort. It is, therefore, imperative that practitioners across specialties, including internal medicine and medical oncology, radiology and surgery maintain current knowledge of these agents and their associated diverse toxicity profiles. This session is designed to provide attendees the opportunity to gain exposure to the current state-of the-art knowledge regarding optimizing patient selection, the role of surgery and radiotherapy in the context of immunotherapy and to explore our current knowledge regarding the safety of drug rechallenge following an immune-related adverse event.
• Attendees will be provided with tools to narrow knowledge gaps with regards the use of biomarkers to optimize patient selection for cancer immunotherapy, including complex surgical- and radio-immunotherapy combinations. In addition, attendees will be better able to identify at-risk patients for immunotherapy toxicity and render informed decisions regarding risk assessment for drug rechallenge in day-to-day practice.

References:

1. Dolladille C, Ederhy S, Sassier M, Cautela J, Thuny F, Cohen AA, Fedrizzi S, Chrétien B, Da-Silva A, Plane AF, Legallois D, Milliez PU, Lelong-Boulouard V, Alexandre J. Dolladille C, et al. Immune Checkpoint Inhibitor Rechallenge After Immune-Related Adverse Events in Patients With Cancer. JAMA Oncol. 2020 Jun 1;6(6):865-871. doi: 10.1001/jamaoncol.2020.0726.
2. Haanen J, Ernstoff M, Wang Y, Menzies A, Puzanov I, Grivas P, Larkin J, Peters S, Thompson J, Obeid M.  Rechallenge patients with immune checkpoint inhibitors following severe immune-related adverse events: review of the literature and suggested prophylactic strategy.  J Immunother Cancer. 2020 Jun;8(1):e000604. doi: 10.1136/jitc-2020-000604.J Immunother Cancer. 2020. PMID: 32532839
3. Bakos O, Lawson C, Rouleau S, Tai LH.Bakos O, et al. Combining surgery and immunotherapy: turning an immunosuppressive effect into a therapeutic opportunity.  J Immunother Cancer. 2018 Sep 3;6(1):86. doi: 10.1186/s40425-018-0398-7
4. Bodor JN, Boumber Y, Borghaei H.Bodor JN, et al. Biomarkers for immune checkpoint inhibition in non-small cell lung cancer (NSCLC).   Cancer. 2020 Jan 15;126(2):260-270. doi: 10.1002/cncr.32468. Epub 2019 Nov 6
5. Justin A Chen, Jonathan W Riess.  Optimal Management of Patients with Advanced NSCLC Harboring High PD-L1 Expression and Driver Mutations Curr Treat Options Oncol Actions. 2020 Jun 25;21(7):60. doi: 10.1007/s11864-020-00750-y.
6. Wang Y, Liu ZG, Yuan H, Deng W, Li J, Huang Y, Kim BYS, Story MD, Jiang W.Wang Y, et al. The Reciprocity between Radiotherapy and Cancer Immunotherapy.   Clin Cancer Res. 2019 Mar 15;25(6):1709-1717. doi: 10.1158/1078-0432.CCR-18-2581. Epub 2018 Nov

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

1. Optimize patient selection for cancer immunotherapy using current knowledge of immunotherapy biomarkers and driver mutations
2. Understand the role of multi-modality immunotherapies, including complex surgical- and radio-immunotherapy combinations. 
3. Identify at-risk patients for immunotherapy toxicity
4. Render informed decisions regarding risk assessment for drug rechallenge in day-to-day practice.

Potential Challenges/Barriers to Change:

1. Financial toxicity/insurance reimbursement
2. Patient willingness to postpone surgery for neoadjuvant immunotherapy
3. Lack of knowledge/expertise in smaller hospital/clinical settings

In this educational session geared towards multidisciplinary NSCLC care teams consisting of medical oncologists, thoracic surgeons, and thoracic radiation oncologists, we will discuss the definitions and scenarios for oligometastatic NSCLC. We will discuss existing randomized data as well as ongoing trials exploring optimal systemic and local therapies of oligometastatic NSCLC. Viewpoints from an expert medical oncologist, thoracic surgeon, and radiation oncologist on the roles of each of the modalities, and sequences of therapies will be provided. We will discuss real-world case scenarios illustrating the importance of multidisciplinary management for oligometastatic NSCLC which is essential to provide the best quality of care in the current era.

Oligometastatic NSCLC is a spectrum of disease with limited sites of metastatic deposits where early local therapy with radiation or surgery in conjunction with optimal systemic therapy may improve progression free survival, survival, and quality of life for patients. Large, randomized data sets do not currently exist to guide ideal treatment decisions. Practitioners need to be aware of ongoing trials in this evolving area as well as the best evidence-based approaches to caring for these patients in their clinic.

• It is imperative that clinicians who manage the care of NSCLC patients know the current existing data regarding treatment of oligometastatic NSCLC with local consolidative therapies.
• Attendees need to apply the latest science and clinical data to determine which patients and in what context and scenarios are most appropriate to offer a metastatic NSCLC patient local consolidative therapy.

References:

1. Palma DA, Olson R, Harrow S, Gaede S, Louie AV, Haasbeek C, Mulroy L, Lock M, Rodrigues GB, Yaremko BP, Schellenberg D, Ahmad B, Griffioen G, Senthi S, Swaminath A, Kopek N, Liu M, Moore K, Currie S, Bauman GS, Warner A, Senan S. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet. 2019 May 18;393(10185):2051-2058. doi: 10.1016/S0140-6736(18)32487-5. Epub 2019 Apr 11. PMID: 30982687.
2. Gomez DR, Tang C, Zhang J, Blumenschein GR Jr, Hernandez M, Lee JJ, Ye R, Palma DA, Louie AV, Camidge DR, Doebele RC, Skoulidis F, Gaspar LE, Welsh JW, Gibbons DL, Karam JA, Kavanagh BD, Tsao AS, Sepesi B, Swisher SG, Heymach JV. Local Consolidative Therapy Vs. Maintenance Therapy or Observation for Patients With Oligometastatic Non-Small-Cell Lung Cancer: Long-Term Results of a Multi-Institutional, Phase II, Randomized Study. J Clin Oncol. 2019 Jun 20;37(18):1558-1565. doi: 10.1200/JCO.19.00201. Epub 2019 May 8. PMID: 31067138; PMCID: PMC6599408.
3. Iyengar P, Wardak Z, Gerber DE, Tumati V, Ahn C, Hughes RS, Dowell JE, Cheedella N, Nedzi L, Westover KD, Pulipparacharuvil S, Choy H, Timmerman RD. Consolidative Radiotherapy for Limited Metastatic Non-Small-Cell Lung Cancer: A Phase 2 Randomized Clinical Trial. JAMA Oncol. 2018 Jan 11;4(1):e173501. doi: 10.1001/jamaoncol.2017.3501. Epub 2018 Jan 11. PMID: 28973074; PMCID: PMC5833648

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Recite the currently available literature on randomized trials for treatment and outcome with local consolidative therapy for oligometastatic NSCLC
2. Describe the optimal agents, duration, and sequence of systemic therapy in the management of oligometastatic NSCLC
3. Describe the role of surgery in the management of oligometastatic NSCLC
4. Describe the role of radiation therapy in the management of oligometastatic NSCLC

Potential Challenges/Barriers to Change:

1. Lack of phase III evidence available to guide treatments for these patients
2. Difficulty with insurance approval for surgery or radiation therapy in oligometastatic NSCLC
3. Lack of experience with optimal treatment techniques to manage these patients

A series of lectures will be provided which will address standard radiologic criteria and procedures used to assess lung cancer patients, what the expected changes and patterns may be in a lung cancer patient who has received SBRT, and finally, what to expected clinically and radiographically in a lung cancer patients who has been treated with immunotherapy. These lectures will be given by expert specialists in these areas who will illustrate criteria and guidelines with example and illustrations. The audience will be encouraged to ask questions and provide their own experiences and examples to supplement these discussions.

While many systemic, surgical, and radiotherapy treatments exist and are effective for lung cancer, it is challenging to assess the efficacy of these treatments in an accurate way. Due to post-treatment changes in the lung, bronchial and mediastinal tissues, the anatomy can be distorted and difficult to assess in a traditional manner. Also, reactions to chemotherapy and immunotherapy can be challenging as these may overlap, mimic, and/or magnify inflammatory changes from surgery or radiation and in some cases, can cause inflammation that can resemble tumor progression. These are also patients who are at high risk of infectious or inflammatory processes unrelated to cancer or cancer therapy. There is a need to standardize definitions of response and educate practitioners on post-treatment assessment of response distinguishing this from unrelated phenomena. Furthermore, the increasingly sophisticated analysis of high-resolution CT and/or PETCT with possibilities of radiomic or AI-based analysis is an area of research development. This session will also encourage interdisciplinary engagement proposing guidelines for when expert multidisciplinary consultation is advised.

References:

1. Gyotoku H, Yamaguchi H, Ishimoto H, Sato S, Taniguchi H, Senju H, Kakugawa T, Nakatomi K, Sakamoto N, Fukuda M, Obase Y, Soda H, Ashizawa K, Mukae H. Prediction of Anti-Cancer Drug-Induced Pneumonia in Lung Cancer Patients: Novel High-Resolution Computed Tomography Fibrosis Scoring. J Clin Med. 2020 Apr 7;9(4):1045. doi: 10.3390/jcm9041045. PMID: 32272762; PMCID: PMC7230276.
2. Febbo JA, Gaddikeri RS, Shah PN. Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer: A Primer for Radiologists. Radiographics. 2018 Sep-Oct;38(5):1312-1336. doi: 10.1148/rg.2018170155. Epub 2018 Aug 3. PMID: 30074857.
3. Linda A, Trovo M, Bradley JD. Radiation injury of the lung after stereotactic body radiation therapy (SBRT) for lung cancer: a timeline and pattern of CT changes. Eur J Radiol. 2011 Jul;79(1):147-54. doi: 10.1016/j.ejrad.2009.10.029. Epub 2009 Dec 1. PMID: 19954913.
4. Huang A, Xu Y, Zang X, Wu C, Gao J, Sun X, Xie M, Ma X, Deng H, Song J, Ren F, Pang L, Qian J, Yu Z, Wan S, Chen Y, Pan L, Zhuang G, Liu S, Xue X. Radiographic features and prognosis of early- and late-onset non-small cell lung cancer immune checkpoint inhibitor-related pneumonitis. BMC Cancer. 2021 May 29;21(1):634. doi: 10.1186/s12885-021-08353-y. PMID: 34051746; PMCID: PMC8164260.
5. Costa LB, Queiroz MA, Barbosa FG, Nunes RF, Zaniboni EC, Ruiz MM, Jardim D, Gomes Marin JF, Cerri GG, Buchpiguel CA. Reassessing Patterns of Response to Immunotherapy with PET: From Morphology to Metabolism. Radiographics. 2021 Jan-Feb;41(1):120-143. doi: 10.1148/rg.2021200093. Epub 2020 Dec 4. PMID: 33275541.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

1. Describe expected changes seen on CT and/or PETCT after surgery, SBRT, or immunotherapy.
2. Name the major radiographic criteria used in determining response to therapy.
3. Specify the timelines for pseudoprogression versus true cancer progression.

Potential Challenges/Barriers to Change:

1. Lack of access to radiology facilities for rapid imaging assessment
2. Lack of access to specialist radiology or pulmonology experts to advise on challenging cases
3. Lack of multidisciplinary culture without input from surgical, radiation, or medical oncology colleagues
4. Lack of rapid insurance authorization support to obtain imaging to assess patients

This will be an overview session addressing the state of the art in the major thoracic malignancies, non-small cell and small cell lung cancer, mesothelioma, and thymoma. Focus will be on knowledge gaps in today’s therapies and what the near future is likely to hold. We will also have a patient give their perspective on unmet needs.

We have made a lot of advances in the treatment of thoracic malignancies, and while overall survival has almost doubled over the last decade, there is a lot of need for improvement. This session will be an overview of the major questions facing patients, practicing clinicians and lung cancer researchers over the next decade with regards to patient impact, non-small cell and small cell lung cancer therapies, thymoma and mesothelioma.

• Knowledge: It is imperative that the practicing oncology professional remain current in the rapidly evolving state-of-the-art in the therapy of non-small cell and small cell lung carcinoma, thymoma, and mesothelioma. This session reviews some of the major challenges facing our community now and in the years to come.
• Competence: Attendees need to determine when and how the latest science will affect their day-to-day practice, and thus be able to narrow competency gaps across the various thoracic malignancies. 
• New data is coming out monthly with many recent approvals.
• Knowledge of the latest trial data.
• Apply the latest trial results to practice.

References:

1. Felip et al, Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial, The Lancet 2021 Oct 9, pp 1344-57.
2. Baas et al, Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial. The Lancet 2021, pp 375-386.
3. Horn et al, First-Line Atezolizumab plus Chemotherapy in Extensive-Stage Small-Cell Lung Cancer. NEJM 2018; 379:2220-2229.

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. State the major challenges today in the management of lung cancer, and what the near future likely holds
2. State the major challenges today in the management of mesothelioma and thymoma
3. Understand the impact of this disease on affected patients and families.

Potential Challenges/Barriers to Change:

1. Lack of accurate biomarkers for selection of patients for immunotherapies in every setting
2. Lack of effective second line therapies
3. Trying to balance rapid approvals to get therapies to patients and lack of comparative or long-term data

This will be an overview session addressing the state of the art in the major thoracic malignancies, non-small cell and small cell lung cancer, mesothelioma, and thymoma. Focus will be on knowledge gaps in today’s therapies and what the near future is likely to hold. We will also have a patient give their perspective on unmet needs.

We have made a lot of advances in the treatment of thoracic malignancies, and while overall survival has almost doubled over the last decade, there is a lot of need for improvement. This session will be an overview of presented abstracts addressing major issues facing practicing clinicians and lung cancer researchers over the next decade with regards to non-small cell and small cell lung cancer therapies, and mesothelioma.

• Knowledge: It is imperative that the practicing oncology professional remain current in the rapidly evolving state-of-the-art in the therapy of non-small cell and small cell lung carcinoma, and mesothelioma. This session addresses some of the major challenges facing our community now and in the years to come in the surgical, medical and radiation treatment of thoracic cancers.
• Competence: Attendees need to determine when and how the latest clinical studies will affect their day-to-day practice, and thus be able to narrow competency gaps across the various thoracic malignancies. 

References:

1. Saji et al, Improved lymph node staging in early-stage lung cancer in the national cancer database: commentary. J Thoracic Disease 2018, S1092-S1095
2. Ramella et al, Proton beam or photon beam radiotherapy in the treatment of non-small-cell lung cancer. The Lancet, 21(7), p 873-875, 2020.
3. Paik et al, Tepotinib in Non–Small-Cell Lung Cancer with MET Exon 14 Skipping Mutations, NEJM 2020: 383:931-943.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand the recommendations for nodal sampling during lung cancer resection
2. Describe some of the issues involved in radiation of thoracic malignancies
3. Explain the efficacy of tepotinib in MET amplified NSCLC.

Potential Challenges/Barriers to Change:

1. Normal tissue toxicity of therapeutic radiation
2. Value of additional effort required to sample lymph nodes during surgical resection of NSCLC.
3. Adequate biomarker analysis of NSCLC to allow selection of targeted therapies.

Immunotherapy, including monoclonal antibodies targeting the immune checkpoints PD-1, PD-L1, and CTLA-4, have revolutionized the treatment of a growing list of cancers over the past decade. Recent advances in this field highlight support for immunotherapy in the neoadjuvant setting. Toxicities referred to as immune related adverse events (IrAEs), are typically mild, however severe, and sometimes lethal toxicities have been reported. Current knowledge regarding optimal immunotherapeutic treatment strategies as well as knowledge of toxicity profiles and early recognition of adverse events are will greatly improve treatment outcomes. This session will review our current knowledge in this rapidly evolving field.

Attendees will be provided with educational tools to narrow knowledge gaps and gain exposure to the current state-of the-art knowledge regarding common toxicities associated with immunotherapies and to offer rationale and support for immunotherapy in the neoadjuvant setting.

Attendees will be provided with tools to narrow knowledge gaps regarding newer treatment strategies including neoadjuvant immunotherapies in the cancer setting and to provide tools that help to identify at-risk patient populations for immunotherapy toxicity and current strategies for management of immunotherapy toxicities in day-to-day practice.

• The use of neoadjuvant immunotherapy in the management of patients with cancer is a rapidly evolving field. Toxicity profiles may vary with tumor type being treated, patient population, immunotherapy class, as well as with dual immunotherapy and immunotherapy-chemotherapy combinations. It is imperative therefore that practitioners maintain current knowledge of optimal immunotherapy treatment combinations and strategies and their associated diverse toxicity risk profiles. This session is designed to provide attendees the opportunity to gain exposure to the current state-of the-art knowledge regarding common toxicities associated with immunotherapies and to offer rationale and support for immunotherapy in the neoadjuvant setting.
• Attendees will be provided with tools to narrow knowledge gaps regarding newer treatment strategies including neoadjuvant immunotherapies in the cancer setting and to provide tools that help to identify at-risk patient populations for immunotherapy toxicity and current strategies for management of immunotherapy toxicities in day-to-day practice.

References:

1.  Provencio M, Nadal E , Insa A, et al., Neoadjuvant chemotherapy and nivolumab in resectable non-small-cell lung cancer (NADIM): an open-label, multicentre, single-arm, phase 2 trial Lancet Oncol Actions. 2020 Nov;21(11):1413-1422. doi: 10.1016/S1470-2045(20)30453-8. Epub 2020 Sep 24
2. Shu CA, Gainor JF , Awad MM, et al.  Neoadjuvant atezolizumab and chemotherapy in patients with resectable non-small-cell lung cancer: an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol . 2020 Jun;21(6):786-795. doi: 10.1016/S1470-2045(20)30140-6. Epub 2020 May 7.
3. Forde PM, Chaft JE, Smith KN, Anagnostou V, Cottrell TR, Hellmann MD, et al. Neoadjuvant PD-1 Blockade in Resectable Lung Cancer.  N Engl J Med. 2018 May 24;378(21):1976-1986. doi: 10.1056/NEJMoa1716078. Epub 2018 Apr 16.N Engl J Med. 2018. PMID: 29658848
4. Caroline Huynh C,  Walsh LA,  D Spicer, JD.   Surgery after neoadjuvant immunotherapy in patients with resectable non-small cell lung cancer.  Transl Lung Cancer Res. 2021 Jan;10(1):563-580.  doi: 10.21037/tlcr-20-509.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand rationale for neoadjuvant immunotherapy in the cancer setting  
2. Recognize and treat various toxicities imposed by these agents
3. Characterize patients that are at-risk for immunotherapy toxicity

Potential Challenges/Barriers to Change:

1. Financial toxicity/insurance reimbursement
2. Patient willingness to postpone surgery for neoadjuvant immunotherapy
3. Lack of knowledge/expertise in smaller hospital/clinical settings

There have been significant advances in systemic therapies for subtypes of NSCLC with better activity in CNS disease. This session will address how to incorporate radiation in this scenario to maximize efficacy and decrease risk of adverse side effects of multimodality therapies.

This session will address challenging clinical scenarios that require multidisciplinary approach for management of brain metastatic in patients with advanced NSCLC, highlighting the advances in systemic therapies and how this impacts care and sequence of therapies to optimize outcomes for patients.

• It is imperative that radiation oncologists remain current on advances on effective systemic therapies in NSCLC that have activity in the CNS.
• Delay or omit brain radiation for patients with NSCLC with effective systemic therapies.

References:

1. Goldman et al. Pembrolizumab for management of patients with NSCLC and brain metastases: long-term results and biomarker analysis from a non-randomised, open-label, phase 2 trial. Lancet Oncol. 2020; 21 (5):655-663.
2. Brown et al. Hippocampal Avoidance during Whole-Brain Radiotherapy plus Memantine for Patients with Brain Metastases: Phase III Trial NRG Oncology CC001. J Clin Oncol 38(10):JCO1902767, 2020. e-Pub 2020. PMID: 32058845.
3. Baik et al. Targeted Therapy for Brain Metastases in EGFR-Mutated and ALK-Rearranged NSCLC. JTO 2015; 10(9):1268-1278.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Identify which patients with advanced NSCLC with brain metastatic disease may be appropriate for initial treatment of CNS metastatic disease with effective systemic therapy.
2. Identify which patients with advanced NSCLC with brain metastatic disease should receive SRS versus whole brain radiation.

Potential Challenges/Barriers to Change

1. Lack of coverage for SRS
2. Need for multidisciplinary teams

This will an education session focusing on geriatric oncology and key geriatric syndromes of cognitive impairment and frailty.

We will review normal memory changes associated with aging, recognize how dementia and frailty are different from normal age-related changes, understand “Chemo brain” and frailty can change during cancer treatment, and discuss strategies and interventions to maintain cognition and prevent frailty.

The number of older adults with cancer is increasing precipitously over the next several decade. Geriatric syndromes such a cognitive impairment, frailty, and poor functional status can affect cancer treatment outcomes and quality of life.

• It is imperative that radiation oncology, medical oncology, and surgeons understand and learn the important of cognitive changes and frailty among older adults with cancer.
• Attendees will be asked to evaluate if they are able to perform brief screening tools in clinic and during the table sessions, how to do these screens.
• Attendees will learn brief tools to evaluate both cognition and frailty that could be used in everyday practice. Based on the results, they will learn where to refer patients if deficits are found.

References:

1. https://pubmed.ncbi.nlm.nih.gov/27547701/
2. https://ascopubs.org/doi/full/10.1200/JCO.21.00239
3. https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21406
4. https://www.frontiersin.org/articles/10.3389/fmed.2021.715513/full
5. NCCN Guidelines for Older Adult Oncology: https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Cognitive aging is a not a disease and occurs in every person
2. Dementia is defined by cognitive changes that affect a person’s ability to function independently
3. Chemo brain or cognitive changes during cancer is not dementia
4. Cognitive changes during cancer treatment usually improve over time, especially with cognitive rehab and lifestyle modifications
5. Understand frailty incidence and prevalence
6. Learn tools to evaluate frailty
7. Identify methods of mitigating frailty and improving short-term outcomes of treatment

Potential Challenges/Barriers to Change

1. Lack of time
2. Lack of staff awareness
3. Lack of referral workflows or resource availability for interventions

There are many advances with approval of effective targeted therapies and advances in imaging. Lack of definitive clinical trial data to provide best next step for patients with lung cancer with brain metastatic disease is challenging.

This session will focus on critical and underaddressed survivorship issues that impact cancer care and patients and their families.

• It is critical to stay up to date about the challenges patients face with consequence of increasing costs of therapies and their impacts.
• It is critical to recognize chronic toxicities of therapies and address survivorship in clinical practice.
• It is critical to work with multidisciplinary team to optimize pulmonary function and smoking cessation in patients with lung cancer.
• In this session, attendees will acquire knowledge about topics that address important survivorship issues.

References:

1. Rivas-Perez H et al. Integrating pulmonary rehabilitation into the multidisciplinary management of lung cancer: a review.  Respir Med. 2015 Apr;109(4):437-42. doi: 10.1016/j.rmed.2015.01.001. Epub 2015 Jan 22.Respir Med. 2015. PMID: 25641113
2. World Health Organization. WHO tobacco knowledge summaries: tobacco and postsurgical outcomes 2020. Available at: https://www.who.int/publications-detail/who-tobacco-knowledge-summaries-tobacco-andpostsurgical-outcomes. Accessed June 6, 20
3. McLouth et al. Unmet Care Needs and Financial Hardship in Patients With Metastatic Non-Small-Cell Lung Cancer on Immunotherapy or Chemoimmunotherapy in Clinical Practice. JCO Oncol Pract. 2021 Aug;17(8):e1110-e1119. Doi: 10.1200/OP.20.00723.
4. Lee et al. Assessment of Parking Fees at National Cancer Institute-Designated Cancer Treatment Centers. JAMA Oncol. 2020;6(8):1295-1297. doi:10.1001/jamaoncol.2020.1475

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Address factors to decrease risk of financial toxicities for patients during the initial phase of treatment planning
2. Focus on improving supportive care for patients with chronic toxicities after cancer care therapies
3. Work with multidisciplinary team to address improving pulmonary function and smoking cessation

Potential Challenges/Barriers to Change

1. Barriers related to insurance coverage
2. Lack of knowledge re: financial toxicity
3. Lack of data on how to improve chronic toxicities

We will review recent changes in the management of resected NSCLC as well as the management of patients with early-stage NSCLC treated with SBRT.

• Recent drug approval and phase 3 trials of post-operative RT have changed the therapy for resected NSCLC

References:

1. Felip et al Lancet 2021: Adjuvant atezolizumab
2. Wu et al NEJM 2020: Adjuvant osimertinib
3. Le Pechoux et al ESMO 2020: Post-operative RT

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Review of adjuvant targeted therapies and immunotherapy
2. Review of the role of post-operative radiation therapy
3. Review of patient management after completion of SBRT

Potential Challenges/Barriers to Change:

1. Dissemination of knowledge of updates
2. Debate within the field about the role of the novel therapies
3. Unwillingness to change current practice patterns

The landscape and modalities for tumor-based and circulating molecular diagnostics to decide treatment with targeted therapies and immunotherapies in patients with lung cancer is rapidly evolving. Limitations in knowing current standards and recommended best practices could negatively impact the quality of care. Understanding the spectrum of molecular diagnostics is also critical to support clinical and translational research.

In this session we will discuss four topics related with advanced precision diagnostics in the context of patients with thoracic malignancies. The first presentation will discuss and update optimal strategies to assess molecular biomarkers in tumor tissue samples and their impact in patient care. The second presentation will focus on the impact of timing for molecular testing to decide optimal treatment initiation using different clinical scenarios. The third presentation will discuss recent developments on the clinical role of non-invasive testing of molecular alterations using liquid biopsy through analysis of ctDNA. The final presentation will discuss controversial areas of immune-oncology diagnostics as well as biomarkers under development and future directions in the field. The session will close with a 15-min Q&A.

• It is critical that information about advanced cancer diagnostics impacting the care of patients with thoracic malignancies is known by all professionals interacting with these patients. It is also relevant to understand state-of the-art technologies and biomarker testing platforms. This meeting session will directly address these points and is expected to fulfill the needs for multispecialty attendants.
• Attendees will learn how and when to use advanced cancer diagnostics. The session will include the discussion of clinical scenarios to highlight optimal strategies to use advanced molecular diagnostics to optimally drive patient care in the context of thoracic oncology.

References:

1. Saller JJ, Boyle TA. Molecular Pathology of Lung Cancer. Cold Spring Harb Perspect Med. 2021 Nov 8:a037812. doi: 10.1101/cshperspect.a037812. PMID: 34751163
2. Malapelle U, Pisapia P, Addeo A, Arrieta O, Bellosillo B, Cardona AF, Cristofanilli M, De Miguel-Perez D, Denninghoff V, Durán I, Jantus-Lewintre E, Nuzzo PV, O'Byrne K, Pauwels P, Pickering EM, Raez LE, Russo A, Serrano MJ, Gandara DR, Troncone G, Rolfo C. Liquid biopsy from research to clinical practice: focus on non-small cell lung cancer. Expert Rev Mol Diagn. 2021 Oct 11:1-14. doi: 10.1080/14737159.2021.1985468. PMID: 34570988
3. Doroshow DB, Sanmamed MF, Hastings K, Politi K, Rimm DL, Chen L, Melero I, Schalper KA, Herbst RS. Immunotherapy in Non-Small Cell Lung Cancer: Facts and Hopes. Clin Cancer Res. 2019 Aug 1;25(15):4592-4602. doi: 10.1158/1078-0432.CCR-18-1538. PMID: 30824587

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand the optimal and current clinical use of molecular testing for patients with lung cancer.
2. Know the current landscape of biomarkers for targeted therapies and immunotherapy for patients with thoracic malignancies.
3. Know emerging developments in the area of precision diagnostics and use of non-invasive biomarker strategies.

As lung cancer screening becomes more broadly implemented throughout academic and private practices, guidance regarding who should be screened, how screening should be performed, how screening CT should be interpreted/reported, and appropriate management of screen detected lung cancers all will be required to maximize the potential mortality benefit, and minimize the risks associated with screening. This session focuses on current screening recommendations, technical aspects of performing lung cancer screening and appropriate staging evaluation of patients with known or suspected lung cancer.

Three sessions are planned. The covers the indications, and pitfalls associated with lung cancer screening. The second presents the Radiologist’s perspective of screening, including pitfalls in interpreting screening CT scans, importance of adherence to reporting guidelines, and description of incidental findings. The final speaker will discuss the staging evaluation of patients with suspected lung cancer, and the importance of staging in treatment and long-term outcomes.

Attendees must know that lung cancer screening is best performed in individuals who are otherwise healthy, at very high risk for lung cancer, and, most importantly, asymptomatic at the time of screening. Attendees should know that the balance of benefits and risks in lung cancer screening and populations too sick to undergo lung cancer surgery is uncertain.

References:

1. Thoracic Oncology: Guideline and Consensus Statement. CHEST 160, ISSUE 5, P1959-1980, NOVEMBER 01, 2021. Executive Summary: Screening for Lung Cancer: Chest Guideline and Expert Panel Report
2. US Preventive Services Task Force. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(10):962–970. doi:10.1001/jama.2021.1117
3. Chronic obstructive pulmonary disease (COPD) and lung cancer screening. Transl Lung Cancer Res. 2018 Jun; 7(3): 347–360

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Attendees will be able to describe the current recommendations for lung cancer screening
2. Attendees will understand how CT scans are obtained interpreted, and reported
3. Attendees will understand appropriate staging evaluation of screen detected lung cancers

Potential Challenges/Barriers to Change:

1. Lack of awareness of lung cancer screening criteria and the risks/benefits on a population level.
2. Misunderstanding of the importance of proper interpretation and reporting of screening findings.
3. Improper application of screening modalities that result in accurate over- or under-staging of patients with suspected lung cancer.

The role of surgery in patients with locally advanced NSCLC remains controversial, with the determination of “resectability” left to the judgement of the surgeon with conflicting data to support decision-making. By highlighting the options available, we will offer guidance to participants in determining when surgery may be indicated for patients with locally advanced NSCLC. Similarly, proton therapy facilities and the use of proton therapy have been proliferating despite a paucity of data to support its use over standard external beam IMRT. We will present the pros and cons of each method to improve the participants understanding of scenarios in which each modality may play a favored role.

The session will consist of two 30-minute debates. The first debate will consist of two thoracic oncologists with one arguing for the use of surgery and one against the use of surgery for patients with stage III NSCLC. The second debate will pit two radiation oncologists with one arguing for proton beam therapy and the other for standard IMRT for treatment of patients with locally advanced NSCLC. Each discussant will have about 10 minutes to present their argument followed by 10 minutes for rebuttal and questions from the moderator and audience.

• All multidisciplinary care team providers need to know the data supporting various treatment options for patients with locally advanced NSCLC.
• It is necessary for all care team providers to understand the benefits and risks of both surgery and various forms of RT in patients with locally advanced NSCLC in order to be able to discuss appropriate options with patients and enhance shared decision-making regarding the optimization of curative therapy.
• After completion of this session, participants will be able to discuss the pros and cons of various options and treatment modalities for patients with locally advanced NSCLC.

References:

1. Cortala, et al. Treatment decision drivers in stage III non-small cell lung cancer: Outcomes of a web-based survey of oncologists in the United States. JCO Oncology Practice 16:693, 2020.
2. Moore, et al. Real-world treatment of stage III NSCLC: The role of trimodality treatment in the era of immunotherapy. J Thorac Oncol 14:1430, 2019.
3. Liao, et al. Baysian adaptive randomization trial of passive scattering proton therapy and intensity-modulated photon radiotherapy for locally advanced non-small cell lung cancer. J Clin Oncol 36:1813, 2018.

Expected Results:

• Increase participants level of knowledge and skills in discussing treatment options for patients with stage III NSCLC.

Upon completion of this live activity, attendees should be able to do the following:

1. Discuss the benefits and risks of trimodality therapy vs. chemoradiotherapy for patients with stage III NSCLC
2. Discuss the benefits and risks of proton therapy vs. IMRT for patients with stage III NSCLC
3. Educate patients and assist in shared decision-making regarding curative treatment options for stage III NSCLC

Potential Challenges/Barriers to Change:

1. Many thoracic surgeons and oncologists are convinced of the benefits of surgery in locally advanced NSCLC despite the lack of trials supporting its use.
2. If your institution spends millions of dollars building a proton facility, then radiation oncologists will face pressure to use it to generate revenue.