Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is 60 Gy in 40 fractions BID an appropriate regimen to use for LS-SCLC now?
The reported results are very interesting and potentially practice changing. The 45 Gy BID was developed in 1983, doubted since then but undefeated in large prospective trials including the RTOG/CALGB trial presented at ASCO. Its 5 week arm with partial 1.8 BID for part was dropped. Four weeks BID w...
Would you consider neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer who are cisplatin-ineligible?
We have level 1 evidence supporting neoadjuvant cisplatin-based chemotherapy followed by cystectomy, there is no evidence supporting non-cisplatin based chemotherapy. Patients unfit for cisplatin should proceed directly to surgery.
Is there any role for ctDNA testing after surgery or SBRT for Stage IB NSCLC to determine the need for adjuvant chemotherapy?
This is another emerging use for ctDNA that has shown promising results in small studies. The TRACERx consortium in the UK looked at the evolution of early NSCLC over time in 100 patients who underwent resection. They performed multi-region sampling and whole-exome sequencing and created patient-spe...
How will your management of head and neck cancers change with the COVID-19 pandemic?
Short answer: Most head and neck cancer radiation is as necessary as it gets. At this point, my management won't change very much. That may change as the pandemic evolves. Use all the appropriate precautions to stop the spread of COVID-19 and other viruses (we are using masks for every staff member,...
What criteria do you use in deciding whether or not to treat the pelvis in prostate cancer?
NRG/RTOG 0924 - The end of elective nodal RT in localized prostate cancer? Top line results: NRG/RTOG 0924 is a very large phase III randomized trial powered for overall survival (OS) to determine if there is a benefit of the addition of whole pelvic radiotherapy (WPRT) to prostate RT plus ADT. This...
In the wake of the COVID-19 pandemic, are there any hypofractionated regimens (without concurrent chemotherapy) that could be utilized for head /neck cancer in a post operative setting?
A very recent paper by Eric Hall and David Brenner’s group (Shuryak et al., Int J Radiation Oncol Biol Phys 2019) is titled “optimized hypofractionation can markedly improve tumor control and decrease late effects for head and neck cancer”. Using a recently improved model, they concluded that an opt...
In mCRPC patients who had an initial response to Pluvicto but progress within 12 months, where do you position PSMA radioligand retreatment relative to other next-line systemic options in your sequencing strategy?
After Lu-PSMA therapy, we may consider taxane chemotherapy, Ra-223, ARPI, or clinical trials in addition to Lu-PSMA retreatment. Retreatment may be more heavily considered in patients with prior deep response to Lu-PSMA, high avidity on a repeat PSMA PET, and/or limited candidacy for other treatment...
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...