The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales. Questions are developed by a group of oncology experts in multiple tumor topic areas. The self-assessment questions are aligned with the American Board of Internal Medicine (ABIM)’s Medical Oncology blueprints and ASCO’s Medical Oncology In-Training Exam (ITE) blueprints. 

Find more self-assessment questions at ASCO Education. 

Correct answers are listed at the bottom of the page.

Question 1: Lung Cancer

A 79-year-old woman with newly diagnosed non-small cell lung cancer (NSCLC) comes to see you for consultation. She has a history of hypertension and lives independently. Imaging revealed bilateral pulmonary nodules. Transthoracic biopsy demonstrates squamous carcinoma. PD-L1 is 10%. She was found to have a 1-cm central nervous system metastases for which she has undergone stereotactic radiosurgery. Her performance status (PS) is 0.

What is the most appropriate therapy for this patient?

1. Weekly paclitaxel    
2. Pembrolizumab       
3. Carboplatin
4. Best supportive care alone

Question 2: Skin Cancer

A 60-year-old man was recently diagnosed with Merkel cell carcinoma (MCC) by punch biopsy on his right shoulder. Subsequent local wide excision showed the lesion to be 3 cm in diameter, with MCC also found in the sentinel lymph node. Subsequent completion lymph node dissection revealed three more involved lymph nodes, one of them with extracapsular extension. He is in good health and does not have any history of autoimmune disease, but admits to ongoing sun exposure.

Which of the following is the most appropriate next step?

1. Observation only     
2. Adjuvant radiation with 50 to 60 Gy to the nodal basin to decrease local recurrence; however, survival benefit has not been shown
3. Adjuvant chemotherapy should be recommended as it has shown survival benefit in patients with regional MCC             
4. Adjuvant ipilimumab should be recommended as it has shown to improve 5-year overall survival in patients with stage III MCC

Question 1 Rationale and References

Correct Answer: B. Pembrolizumab

Rationale: In April 2019, the FDA expanded its approval to include use of pembrolizumab in non-small cell lung cancers expressing PD-L1 at ≥ 1%. Thus, pembrolizumab should be considered for this patient with PD-L1 expression of 10%.

In addition, a study presented at the 2019 European Lung Cancer Congress demonstrated efficacy and safety of immunotherapy in elderly patients with advanced non-small cell lung cancer. This pooled analysis of three randomized trials showed significantly improved overall survival in elderly patients with advanced PD-L1-positive NSCLC treated with pembrolizumab compared to those treated with chemotherapy.

Another study was presented that showed that immune-related adverse events were similar in elderly and younger patients, but that the efficacy of the immunotherapy was reduced in elderly as compared with the younger patients. This was a retrospective study and the PD-L1 status was known in only 50% of patients assessed thus additional data are needed to answer remaining questions.

References:

• ELCC 2019: Immunotherapy in Elderly Patients With Advanced NSCLC. (2019, April 11). Retrieved June 6, 2019, from https://www.ascopost.com/News/59925.
• Center for Drug Evaluation and Research. (2019, April 11). FDA expands pembrolizumab indication for first-line treatment of NSCLC. Retrieved June 7, 2019, from https://www.fda.gov/drugs/fda-expands-pembrolizumab-indication-first-line-treatment-nsclc-tps-1.

Question 2 Rational and References

Correct Answer: B. Adjuvant radiation with 50 to 60 Gy to the nodal basin to decrease local recurrence; however, survival benefit has not been shown

Rationale: Radiation to the nodal basin is recommended for patients with either multiple lymph nodes and/or extracapsular extension.  Adjuvant chemotherapy is not routinely recommended as survival benefit has not been established. Ipilimumab in the adjuvant setting is reserved for patients with melanoma.

References:

• Jouary T et al. Adjuvant prophylactic regional radiotherapy versus observation in stage I Merkel cell carcinoma: a multicentric prospective randomized study. Ann Oncol. 2012;23:1074-80.
• Jabbour J, Cumming R, Scolyer RA, et al. Ann Surg Oncol. 2007;14:1943-52.                              
• Eggermont AM, Chiarion-Sileni V, Grob J-J, et al. New England Journal of Medicine. 375:1845-55.

Originally published in September 2019; reviewed and updated October 2021.