Appointment sheet
Resectable stage I to III non-small-cell lung cancer
Prepared with OnCo (onco.cc/prep/resectable-nsclc/). Orientation, not medical advice; your team knows your case.
My details
Name
Date of appointment
Hospital and clinician
Who is coming with me
What I know, what is unclear, changes to discuss
Saved in this browserWhat I know so far
What is unclear to me
Changes since last time
My questions
21 on the sheetNewly diagnosed
- 1.What is my exact diagnosis, stage, and grade, and which tests established them?
- 2.Which biomarkers have been tested on my tumour (for example TNM stage by PET-CT, brain MRIand mediastinal sampling by endobronchial ultrasound or mediastinoscopy, EGFR and ALK status before any systemic treatment, PD-L1 tumour proportion score, Pathological complete and major pathological response after neoadjuvant therapy, Circulating tumour DNA after surgery), and what were the results?
- 3.Which subtype is my cancer, and does that change the recommended treatment?
- 4.Is germline (inherited) genetic testing recommended for me or my family?
Stage IA, peripheral, 2 cm or less
- 5.For my situation (stage ia, peripheral, 2 cm or less), which of the standard options do you recommend and why?
- 6.How do the results of CALGB 140503 (Alliance) and CHISEL (TROG 09.02) apply to someone like me?
Stage IB to IIIA without EGFR or ALK alteration
- 7.For my situation (stage ib to iiia without egfr or alk alteration), which of the standard options do you recommend and why?
- 8.Am I a candidate for Nivolumab, Pembrolizumab, Durvalumab or related drugs, and what side effects should I expect?
- 9.How do the results of CheckMate 816 and KEYNOTE-671 apply to someone like me?
Resected EGFR-mutated stage IB to IIIA
- 10.For my situation (resected egfr-mutated stage ib to iiia), which of the standard options do you recommend and why?
- 11.Am I a candidate for Osimertinib, and what side effects should I expect?
- 12.How do the results of ADAURA apply to someone like me?
Resected ALK-positive stage IB to IIIA
- 13.For my situation (resected alk-positive stage ib to iiia), which of the standard options do you recommend and why?
- 14.Am I a candidate for Alectinib, and what side effects should I expect?
- 15.How do the results of ALINA apply to someone like me?
Staging and surveillance
- 16.For my situation (staging and surveillance), which of the standard options do you recommend and why?
Any stage
- 17.Are there clinical trials I could join, for example of MRD / molecular residual disease testing, Circulating tumour DNA (ctDNA), A Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Removal and Adjuvant Treatment With Nivolumab or Placebo for Participants With Surgically Removable Early Stage Non-small Cell Lung Cancer, Formally qualify tumour-DNA blood tests as a surrogate endpoint for adjuvant trials?
- 18.Would a second opinion at a high-volume centre change anything, and can you help arrange it?
- 19.What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
- 20.I read that “Whether adjuvant immunotherapy adds anything after neoadjuvant treatment and surgery, especially for complete pathological responders, has not been tested directly”. How does that affect my plan?
- 21.I read that “Circulating tumour DNA after surgery identifies high-risk patients but no trial yet shows that acting on it improves survival”. How does that affect my plan?
The words I may hear
- Stage: How far a cancer has spread, from stage I (small and confined) to stage IV (spread to distant organs).
- Minimally invasive surgery (laparoscopic, robotic, VATS): Any operation done through small incisions with cameras and long instruments, including robot-assisted surgery; the cancer operation is the same, the wound is smaller.
- Segmentectomy (sublobar resection): Removing only a segment or wedge of a lung lobe rather than the whole lobe, sparing breathing capacity.
- TNM staging: TNM staging is the universal system describing tumour size (T), lymph node spread (N), and distant metastasis (M).
- EGFR exon 19 deletion & L858R: Exon 19 deletion and L858R are the two common EGFR mutations, together ~85% of EGFR-mutant lung cancer, and both respond to EGFR pills.
- Major pathological response (MPR): When, after pre-surgery treatment, the removed tumour contains little or no living cancer: 10% or less viable cells.
- Pneumonectomy: Removing an entire lung.
- Lobectomy: Removing one lobe of the lung (the right lung has three, the left two).
- Bronchoscopy (EBUS, robotic navigation): Passing a camera down the windpipe into the lungs to biopsy tumours and lymph nodes without surgery.
- Event-free / disease-free survival (EFS, DFS, iDFS, RFS): In early-stage cancer: how long patients stay free of recurrence, progression, or death.
Tests and results to bring
Staging and surveillance: PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.
Biomarker results to ask for: TNM stage by PET-CT, brain MRI (stage II and above) and mediastinal sampling by endobronchial ultrasound or mediastinoscopy, EGFR and ALK status before any systemic treatment (targeted adjuvant therapy; neoadjuvant immunotherapy avoided), PD-L1 tumour proportion score (adjuvant atezolizumab and pembrolizumab eligibility), Pathological complete and major pathological response after neoadjuvant therapy, Circulating tumour DNA after surgery (molecular residual disease; under study), Pulmonary function and cardiac fitness for surgery.
Scans and tests linked to this cancer: CT (computed tomography), Low-dose CT lung screening, MRI, PET/CT, MRD / molecular residual disease testing, Robotic and navigational bronchoscopy.
Bring copies of scan reports, pathology and blood results, and a list of every medicine and supplement.
The treatments I may be offered
- Stage IA, peripheral, 2 cm or less: Segmentectomy or lobectomy by video-assisted or robotic thoracoscopy with node dissection (CALGB 140503, JCOG0802); no systemic therapy; stereotactic radiotherapy if not fit for surgery. (CALGB 140503 (Alliance), Lobectomy, Segmentectomy (sublobar resection), Robotic & minimally invasive surgery, Minimally invasive surgery (laparoscopic, robotic, VATS), SBRT / SABR (stereotactic radiotherapy), CHISEL (TROG 09.02), JCOG0403)
- Stage IB to IIIA without EGFR or ALK alteration: Neoadjuvant nivolumab plus platinum chemotherapy for three cycles (CheckMate 816) or perioperative pembrolizumab (KEYNOTE-671), durvalumab (AEGEAN) or nivolumab (CheckMate 77T) with chemotherapy before and immunotherapy for a year after surgery; or surgery first then adjuvant cisplatin doublet and atezolizumab or pembrolizumab if PD-L1-positive (IMpower010). (CheckMate 816, Nivolumab, KEYNOTE-671, Pembrolizumab, A Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung Cancer, Durvalumab, A Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Removal and Adjuvant Treatment With Nivolumab or Placebo for Participants With Surgically Removable Early Stage Non-small Cell Lung Cancer, Study to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [, Atezolizumab, Cisplatin, Carboplatin, Pemetrexed, Neoadjuvant / adjuvant / perioperative, Pathologic complete response (pCR), Major pathological response (MPR))
- Resected EGFR-mutated stage IB to IIIA: Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA). (ADAURA, Osimertinib, EGFR exon 19 deletion & L858R)
- Resected ALK-positive stage IB to IIIA: Two years of adjuvant alectinib in place of chemotherapy (ALINA). (ALINA, Alectinib)
From the standard of care recorded for this cancer; which apply depends on your stage and biomarkers. Ask which the team recommends and why.
Answers and next steps
Saved in this browserWhat I was told
Agreed next steps, dates and who to call