Radiation Oncology

Medical Oncology   

Questions discussed in this category

Specifically with reference to rural settings where the logistics of early in the week delivery may be more challenging.

Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?

This question has come up most frequently with respect to the flu vaccine recently. Also, frequently this has been asked about the shingles vaccine an...

Would you recommend it for a mammographically occult primary or if the patient had dense breasts?  What if a high risk patient decides not to hav...

Aside from smoking cessation, what interventions have you found useful to manage patients with chronic symptomatic laryngeal edema? Steroids seem to b...

In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...

i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...

The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...

For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...

Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...

Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...

NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?

Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?

The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.

Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?

Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...

The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...

One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...

Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.

If so, what dose-fractionation regimen do you utilize? What are your target volumes?

Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?

Should cystectomy remain standard of care? (Recently debated in JAMA Oncology: http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...

Some specific questions: Would you recommend repeat biopsy to confirm residual disease? How would your recommendations vary if the patient had pre...

In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial. https://www.ncbi.nlm.nih.go...

For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?

Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?

How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...

Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...

Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?

What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...

Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.

Some ENTs advocate for a neck dissection as a way to avoid chemotherapy if there is a high chance there is no ECE. This is without removing the primar...

What clinical criteria would make you prefer TORS as the initial treatment approach?  

Would you follow an algorithm such as the one proposed by Hall et al? How do you decide between intrathecal chemotherapy vs systemic therapy with HD-...

Would you proceed with induction chemotherapy (eg TPF or cis/gem) to downstage or neoadjuvant chemoRT? Would your approach be different if there is or...

Do you feel it is important to start durvalumab within 14 days of completing cCRT?  What real life challenges do you face in doing so and wh...

Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes?  Do you utilize EBRT?

How do you decide?  Do the results of recently published phase III data in the Lancet Oncology (Sun et al, Sept 2016) influence your decisio...

Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...

Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...

Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...

Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? 

If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?

The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...

For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...

If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?

The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...

What features would make you more likely to recommend radiation therapy with chemotherapy?

No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.

A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...

Do your recommendations differ if patients are pre or postmenopausal given the data?

Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?

There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...

Do you ever start radiation +/- 24-48 hrs from C1D1 for chemotherapy due to logistical barriers? Do you prefer chemotherapy to start at beginning of ...

Which appetite stimulants are the most effective? How do you respond to patients who request medical marijuana?

Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...

Is concurrent chemotherapy necessary for these patients?

Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...

Does papillary histology influence your decisions regarding surgery, chemo, radiation dose or nodal coverage?

For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...

If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...

Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...

Routinely? Only with oropharyngeal cancer etc.? Given that low expression of EGFR subset did better, do you believe there is a true benefit in cetuxim...

Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...

Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...

Would you use the same schedule as early stage NSCLC primary?

The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...

Based on the UK OnCoRe matched cohort analysis, would you offer a watch-and-wait approach off protocol or are you uncomfortable treatin...

Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?

Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?

A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...

I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...

I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...

Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

If so, what fields do you irradiate? The initially involved nodal regions? If not, do you consolidate at any point in the future (ie after a loca...

By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...

If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...

What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?  

Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...

These patients have been largely excluded from these trials.  What if the infection is well controlled?

Do you refer all patients who are felt to be at high risk to a genetic counselor for testing or are you comfortable performing a MyRisk panel in your ...

I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...

If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...

http://www.nejm.org/doi/full/10.1056/NEJMoa1612645?rss=searchAndBrowse&#article_abstract If so, how do you sequence it with adjuvant radiotherapy...

What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?

Obviously the details matter a lot, but are there guiding tenets one should follow beyond expressing condolences to the family?

This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...

This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...

For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?

How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...

The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...

What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...

If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?

Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g. skin canc...

If so, how do you manage counseling for someone with low health literacy?

When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...

If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...

The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.

Do you offer neoadjuvant RT with resection and node dissection vs. definitive radiation?  How extensive does the nodal disease have to be for you...

Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage? 

In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?

My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...

Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?

Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...

PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...

Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?

In a patient who already received 13 courses of radiation (with complete response), is there any other effective treatment?

In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...

To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?

Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...

Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...

If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?

Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...

For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well. 

With the current data, I'm struggling to justify addition of radiation for potentially resectable disease.  If in favor of RT, do you recommend s...

Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound?  I...

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

Would your recommendations change if it was a partial vs complete radiographic response?

Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?

How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation? 

Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...

The immediate response by patients in this situation seems almost universally to be, "But I'll starve to death!" Referencing literature about lack of ...

How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...

For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...

Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost.  Does the cost-effectiveness fa...

This is rarely done, but recently came up in a tumor board discussion.  Which chemotherapy would you consider using, and when?

In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?

Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...

Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?

Does the site of palliative radiation therapy matter (i.e. femur, abdomen, pelvis vs base of skull)? How long should you wait to give palliative ...

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib. 

Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...

What do you consider when making this decision (concurrent chemotherapy, amount of bone marrow in field, whether patient is already on antibiotics, et...

If so, when? Although anemia is associated with worse local control in HN cancer, I don't know of any data that shows that blood transfusions can help...

Is there data supporting the idea that chemotherapy must be onboard prior to delivering radiation for maximal radiosensitization (particularly for hea...

If not what radiation fractionation regimen is preferred for otherwise good KPS patient? 

Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...

Do you have a preference for specific steroids? Some practices may switch to prednisone during this time.   Patients with gliomas are often on d...

In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...

In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...

We have a great palliative care clinic and I like to refer many patients with metastatic disease, even if I feel that they will live a year or two lon...

Is there any consensus regarding the optimal RT dose, fractionation, and timing to the best abscopal response? What is the optimal metastatic site to ...

If the systemic agent is going to be held, how many days prior to starting radiation therapy should the agent be held and when can it be restarted aft...

 In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...

As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?

The NCCN guidelines discourage the use of PET/CT surveillence but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...

Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...

I know that some would argue that healthy patients with an excellent performance status may not need an early palliative care referral, but wouldn't i...

In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...

Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.

Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...

What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...

I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...

Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...

If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...

Do the potential late effects offset any benefit of mediastinal XRT in a young patient with bulky disease?

Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...

Do you try to keep Hb> 10 or 12? Or somewhere in between? 

Even though we do not have the best data on the use of induction chemotherapy, what are current practices?

I am curious as to how others approach this question coming from a patient with metastatic cancer. How do you "have the talk" in a way that is straigh...

Papers discussed in this category

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