Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you offer consolidation chemotherapy for patients receiving chemoradiation for locally advanced NSCLC?
I rarely use consolidation therapy. When I do, it is usually because of lapses in or missed chemoRT treatments. We have two randomized studies that show no benefit to consolidation therapy.
How would you manage a patient with prostate cancer who has a history of total colectomy with primary anastomosis and is not a surgical candidate?
We favor brachytherapy alone in these patients. One patient we treated recently with history of IBD and J pouch after total colectomy, we tried space OAR which was difficult because of surgical scarring and the space craeted was not as optimal as patients without previous prior surgeries. However, w...
Do you have a methodical procedure for checking treatment plans before approving?
When I was a resident, an attending taught me a methodical plan for approving plans which I still teach my residents. There's nothing magical at all about it, but somehow when there are four easy steps, it's easier to follow: 1. Review the plan in axial imaging from top to bottom reviewing coverage ...
Do you ever withhold adjuvant RT after BCS in older women with stage I triple positive/Luminal-Her2 subtype breast cancers?
If they receive herceptin-based chemotherapy, then local regional recurrence rates are similar to luminal A disease (excellent review on this subject by Wendy Woodward during her talk at ASTRO in 2016- accessible on virtual meeting). So by that logic, you could consider it in someone who has receive...
Do you ever withhold PCI for elderly patients with limited stage SCLC?
In my opinion, the findings by Takahashi et al, Lancet 2017 regarding the lack of survival benefit of PCI as compared to MRI observation in patients with extensive SCLC has re-opened the question of the survival benefit of PCI in limited SCLC in the modern imaging era. Hopefully, a phase III study o...
When TPN is a barrier to enrollment in hospice for an eligible cancer patient with an irreversible malignant bowel obstruction, how do you approach the conversation about discontinuation of TPN?
This is such a tough question with no great answer. With any difficult conversation like this, I usually take this approach: 1) Understand what the patient's goals are. ("What's most important to you?") 2) Usually they say living as long as possible/as well as possible 3) Acknowledge that goal as r...
How would you approach definitive nonsurgical management for biopsy-proven, localized small cell carcinoma of the prostate?
Rare disease and one patient we treated with cis plus etoposide with RT added with second cycle. Because of concern about unsampled mixed high grade histology we planned to treat to 70 Gy. No PCI as isolated brain relapse for pelvic small cell is not same as for small cell of lung
How should a patient be treated when they have an isolated para-aortic recurrence after upfront chemotherapy and vaginal cuff brachytherapy for intermediate risk endometrioid endometrial adenocarcinoma?
We treat with salvage RT to involved nodal region (pelvis and pa if no prior EBRT and pa only if prior EBRT to pelvis) with concurrent and sequential or sequential chemotherapy using IMRT technique and using SIB dose with 55 Gy in 25 fractions to involved node and 45 Gy in 25 fractions to prophylact...
How would you treat a patient with widely metastatic clear cell RCC who has undergone craniotomy/resection of a single brain metastasis?
Initial therapy in the front line setting for a person with widel metastatic disease would include either sunitinib or pazopanib. I would not use IL2 in this setting because of the recent brain surgery. Clinical trials should also be considered,
How do you logistically give sandwich chemotherapy and whole pelvis radiation treatment in advanced endometrial cancer?
We prefer concurrent or sequential. But in the past when we have done sandwich, we have used RT after 3 cycles of chemotherapy based on most of the published data.