Palliation   

Questions discussed in this category



We have been receiving referrals for oligoprogressive SBRT for multiple primary tumors (NSCLC, Colorectal, Renal Cell, etc.) in the setting of diffuse...

Would you consider using radiotherapy for persistent malignant pericardial effusion?  What dose-fractionation would you use, and what would your ...

Is there specific workup you perform? Are there preventive measures? Once established, are there non-pharmacological and pharmacological treatments yo...

For that occasional "single lymph node metastasis" referral in patients with no other sites of disease, is there a therapeutic dose below which you're...

Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...

Is your size limit a function of OAR dose? If yes, is there a volume of bone that you will not exceed regardless of no dose-limiting OARs?

I have a patient with metastatic NSCLC and a concurrent head and neck primary.

Is there evidence that supports/refutes the safety of concurrent use?

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

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

How about those with metastatic disease eager to maintain quality of life? Do you risk progression of disease if the TNF blocker is re-started?

What is your normal dose-fractionation in this scenario? Do you change your dosing if the lesion is in a weight bearing structure (femoral head/neck,...

Is urgent whole brain radiotherapy indicated for certain histologies such as choriocarcinoma from GTN or testicular origin? If SRS is employed, how sh...

What dose-fractionation scheme do you utilize? Are there particular groups of patients this would not be a good option for (i.e. histologies of diseas...

Would you offer palliative radiation? Would you fractionate differently?

If so, how would you approach your radiotherapeutic plan and what dose-fractionation would you utilize?

Would you treat Dupuytren’s contracture shortly after surgery or wait till patient develops new contracture? What dose and fractionation do you ...

Are you waiting for final publication of NRG CC-001? If already routinely using, any challenges with insurance approval, plan turnaround time, or oth...

Would you consider treating 3-5mm lesions with SBRT or wait until they are a certain size? I am concerned I will not be able to see them adequately on...

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

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

What factors would you consider? What if this meant treatment of the full kidney? If treatment is recommended, would you utilize an SBRT approach...

Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...

Would you continue treating the patient (in spite of the risk of causing a frank perforation, sepsis, and subsequently devastating consequences), or w...

Do you have a "threshold" quantity/dose of opioids above which you are uncomfortable prescribing?

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...

What factors do you consider when determining this constraint? For example, in a patient who was previously treated to 30 Gy in 10 fractions, how woul...

A case series from Colorado raises concern over significant radiation necrosis with SRS. However, there doesn't seem to be much additional negative li...

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

If you are treating a very large palliative spine field that encompasses several vertebral levels, would you consider splitting the field (treating ha...

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

For example, what is a safe dose for SBRT for a ~5 cm colorectal bone metastasis of the acetabulum?

 How does your fractionation choice change if the lesion is abutting the pleura?

Would you use adjuvant radiotherapy after xiaflex injection or needle aponeurotomy?

Would you take any special precautions with dosing or care for fingernail toxicity?

Does fractionation (or location) influence this decision? What is your preferred steroid dose?

Does the time interval between the intial RT and recurrence influence your decision? What time interval would you feel is appropriate? What dose would...

If given options of liver, lung, spine, brain, axilla, or other lymph nodes which sites do you pick?

Would you treat if there is active infection?  How much improvement would you expect?

Would you treat if the patient is asymptomatic?  If you do treat, what dose/fractionation would you use?

How do you decide between plaque brachytherapy and external beam approaches? What dose do you use for plaque brachytherapy? For external beam, what do...

Does your volume change based on fractionation (high-dose single fraction vs. 3-5 fractions)? Do you treat the entire circumference of long bones? Wha...

Would you feel comfortable treating with palliative radiation without neurosurgical assessment? Are these patients at increased risk for neurolog...

There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications. 

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

Are carcinoid tumors of the GI tract more or less radiosensitive than typical solid tumors? 

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

To what degree, if any, is a neurosurgeon involved in the planning of SRS for brain metastases?

The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...

If surgical stabilization has been performed, do you go with SBRT dosing? If so, do you treat only the involved site and not the extent of hardware? D...

Please share your decision algorithm, if any (based on age, histology, KPS, lines of therapy already used, prognosis, etc.).

For example, in someone with a new diagnosis of hormone receptor positive breast cancer with a 10 cm lytic bone lesion extending out into the pelvis a...

For example, would you treat the entire length of the femur after prophylactic intramedullary rod fixation for a femoral neck metastasis?

For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...

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

Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?

For example, if a patient had severe lung obstruction or hemoptysis from a tumor would it be okay to treat with 3Gy per fraction BID? Or, if a pa...

More specifically, what do you classify as a situation that needs treatment within 24 hours?

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 ...

Do you consider placing an Ommaya for IT chemo with methotrexate or cytarabine? Knowing that leptomeningeal carcinomatosis carries such...

What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...

How does your fractionation change based on the time from the previous treatment, such as 6-12 months vs. greater than 12 months?

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

For example, is 8 Gy x 1 well tolerated in the setting of multi-level vertebral body radiation? 

Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?

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...

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...

Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)?  How does the V10 or V12 constraint change ...

Is there a hypofractionated dose regimen that would be suitable for palliation prior to the patient going to hospice?

For a patient who has completed 40 hyperbaric sessions with steroids with little improvement, what other options exist?

If so what dose-fractionation do you use and what constraints for brachial plexus?

The Canadian study presented at ASTRO 2015 showed a decrease in pain flare prior to single dose 8Gy RT, but steroids were given for 5 days prior to RT...

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 treating an oligometastatic lesion in the sacrum, is it reasonable to extrapolate from RTOG brachial plexus contraints (eg, 8 Gy/fx for a 3-fractio...

Do you handle a non-emergent indication such as palliation for pain vs cord compression differently in a patient unwilling to undergo a biopsy?

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

In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?

In a patient with multiple brain metastases from NSCLC, is this reasonable?

Any advice on how to safely incorporate it into our practice?

If progression is proven by imaging modality (MRI spectroscopy, perfusion and PET/CT), is there evidence for retreatment with a second course of SRS?&...

The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...

In reading through the policy of one of my state's private insurance companies, I came across something with which I'm not familiar, namely treating p...

I'm aware of a number of publications that suggest that after 1-2 years, the cord should be able to handle about 50% of the original tolerance dose. &...

My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...

It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...

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

What dose/fractionation is appropriate and does it differ between histology?

Do you hypofractionate or add any concurrent systemic therapy? 

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...


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