Thoracic and Head/Neck Cancers
Core concepts
For non–small cell lung cancer, stage determines intent: surgery or stereotactic radiotherapy for early stage, chemoradiation plus consolidation immunotherapy for unresectable stage III, and biomarker-directed therapy for advanced disease. Biomarkers to know: EGFR sensitizing mutations (osimertinib), ALK and ROS1 rearrangements, BRAF V600E, MET exon 14 skipping, RET and NTRK fusions, KRAS G12C, and PD-L1 expression guiding first-line immunotherapy. Small cell lung cancer is staged limited versus extensive and treated with platinum-etoposide plus immunotherapy, with prophylactic cranial irradiation in selected cases. Head and neck squamous cell carcinoma teaching centers on HPV/p16 status (oropharyngeal, better prognosis), surgery versus definitive chemoradiation, and the role of immunotherapy in recurrent/metastatic disease. Know the toxicity profiles: immune-related adverse events, radiation mucositis, and cisplatin nephrotoxicity/ototoxicity.
Traps
Questions test whether you would give immunotherapy to a patient with an actionable driver mutation (usually no-targeted therapy first), whether stage III disease is resectable, and how PD-L1 thresholds differ by agent and line. Watch for confusing limited versus extensive SCLC and for the p16/HPV prognostic implication in oropharynx.
Rule of thumb
In advanced NSCLC, order molecular testing and PD-L1 before choosing therapy; a targetable driver trumps immunotherapy.
Worked example
A never-smoker with metastatic adenocarcinoma and an EGFR exon 19 deletion: first-line osimertinib, not chemoimmunotherapy, regardless of PD-L1 score.