ICU admission. Alternatives to intubation in cancer patients with acute respiratory failure Noninvasive mechanical ventilation (NIV) and high-flow oxygen therapy (HFNC) have proven effectiveness to reduce intubation in cancer patients with acute hypoxemic respiratory failure but no indications for intubation [32, 35, 36]. HFNC may have both helped to improve outcomes and raised concerns about NIV [9, 26, 35, 36, 123]. However, conflicting data have been published, with no impact of NIV as compared to oxygen in Lemiale’s trial and harmful effect of NIV as compared to HFNC in Frat’s trial [28, 36]. However, Mokart et al.’s retrospective study [124] found no excess mortality with HFNC+NIV. Noteworthy, both the Frat and Lemiale’s trials have been criticized for the lack of optimal NIV delivery. Indeed, in these trials the proportion of patients receiving more than 12 h of NIV per day did not exceed 20%. Also, in the post hoc analysis of Lemiale’s trial, HFNC was not associated with any survival benefits [37]. Confirmatory data are needed to prove benefits of HFNC in immunocompromised patients. To date, no study has evaluated NIV versus intubation in patients meeting the indications for intubation as performed in unselected patients [125]. A study where NIV/CPAP would be evaluated as an alternative to mechanical ventilation in patients with indications for intubation is warranted, especially for cancer patients with ARDS. Here, NIV delivery would be guided by close respiratory monitoring and physiological evaluation such as transpulmonary pressures, ventilator-induced lung injury (by monitoring expiratory tidal volume), and work of breathing.Future of diagnostic strategies for infection Diagnosis of infection and of its resolution based on routine clinical, biochemical, and radiological signs is inaccurate in cancer patients. Standard microbiological workup increases specificity at the cost of longer time to diagnosis, whereas empirical antimicrobial therapy is challenged by the broad range of potential pathogens and their varying antimicrobial susceptibility [100, 126]. These factors led to excessive prescription of antibiotics and antifungals, but also sometimes to undertreatment. Diagnostic strategies may incorporate newer tests with higher diagnostic performances, shorter turnaround time, and easy and noninvasive sampling. These may include classic or new approaches to the use of biomarkers reflecting host response or pathogen invasion and non-culture-based microbiological identification of pathogens [127, 128]. Biomarkers may allow better differentiation of infectious from noninfectious conditions, earlier detection of invasive pathogens, and safer withholding of antibiotic therapy [129, 130]. Molecular techniques such as those based on nucleic acid extraction and amplification may identify pathogens and key resistance genes in less than 12 h and thus guide early antibiotic choices [128]. Research should now focus on interventional trials comparing diagnostic strategies with and without these tests incorporated. Beside mortality, additional outcomes should be economic and ecological costs, such as antimicrobial consumption and emergence of resistance. The cost–benefit ratio of newer diagnostic tests and especially the added value compared with state-of-the-art clinical decision-making [131] should be addressed. In addition to noninvasive samples, these tests also need to be tested in CT-guided fine needle biopsy or endobronchial ultrasound-guided biopsy.