Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How are you using predictive tests such as DCISionRT (PreludeDx) or OncotypeDX DCIS in the management of DCIS?
Advantages: It's a relatively cheap, simple assay to better individualize risk of DCIS. Not only prognostic like Oncotype DCIS but also predictive of the absolute benefit of radiation. Supposed to be a better risk assessment tool than traditional clinical pathologic factors. Can identify those who ...
Given the final publication of NSABP B-51, for which patients meeting trial eligibility would you still recommend regional nodal irradiation?
The very first thing that should occur before one makes a decision about what they are going to do is to understand how the trial was designed and who was actually accrued to it. The first point is that B51 was a superiority and not a non-inferiority trial. A very related point to that is that they ...
In a patient with dMMR rectal adenocarcinoma, does the use of palliative RT for bleeding (5 Gy x 5) preclude the use of immunotherapy?
In dMMR rectal adenocarcinoma, short-course palliative pelvic radiotherapy is the faster, more reliable tool for controlling tumor bleeding than checkpoint inhibitor immunotherapy due to a direct hemostatic effect with bleeding-control rates of roughly 81–100% over days to a few weeks. Immunotherapy...
Does your practice currently use low-dose radiation in the treatment of osteoarthritis?
Yes, we do. There is a long and storied history of utilizing LD-RT for benign inflammatory conditions in Germany. Much of the literature comes from there. I have had great success and truly believe it is a valuable tool to add to our toolbox. Pearls: At this time, I am limiting treatment to osteoar...
How long after achieving a CR would you consider stopping pembrolizumab in metastatic melanoma?
Based on Keynote 001 and more recently on Keynote 006, where we observed sustained remission in more than 90% of the patients who had stopped pembrolizumab for complete response, we usually consider stopping pembrolizumab in patients who have a confirmed complete response (this means that we have tw...
Are there select patients with rectal cancer where radiation field size reduction might be feasible?
Yes, however, how to select which patients could have a field size reduction is unknown. Such a field size reduction is probably even more acceptable in the era of total neoadjuvant therapy, however, this cannot be considered standard of care given the absence of trials evaluating such novel approac...
Given COVID-19, is there a good hypofractionated regimen for postmastectomy radiation for locally advanced breast cancer?
In light of COVID-19, we offer 2.66 x 16 PMRT with comprehensive RNI. This regimen is under study in ALLIANCE A221505, commonly known as RT-CHARM. Primary endpoint is reconstruction complications at 2 years. We discuss with reconstructed patients (most all will take if offered). Routinely given to u...
How do you talk to patients with intermediate-risk prostate cancer deciding between LDR brachytherapy (monotherapy) vs HDR mono vs SBRT vs EBRT, in terms of the comparative side effect profile of each approach?
It’s hard to add much to Dr. @Dr. First Last's excellent evidence-based answer, but I’ll elaborate on the counseling aspect from my perspective. Introduction: I start by acknowledging how difficult it is to weigh several totally foreign options and acknowledge the gravity of the decision. My patient...
If an asymptomatic patient requires a delay up to a week before starting chemotherapy for Stage III lung cancer, do you also push back the radiation start date?
Typically, the reason for B12 and folate prior to chemotherapy is related to the drug that will be used, pemetrexed. Giving the premedication reduces hematologic and gastrointestinal toxicity to tolerable levels. One week typically will not make a difference and I would usually wait to start. Howeve...
How would you boost a high-risk prostate cancer patient who received standard fractionation treatment and is not able to get LDR boost given COVID-19?
I will assume for the sake of argument that he is also getting ADT as part of his treatment. If he has responded well to ADT (I like to see about a 90% drop in the PSA within 3 months), my preference would be to try to delay until it's reasonable from an infectious disease perspective to proceed wit...