Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you manage chest wall pain due to SBRT?
Chest wall pain is not an insignificant consequence of thoracic radiotherapy, especially after SBRT. Most of the data describing chest wall pain comes from the SBRT era. Older literature (breast and lung treatment) tends to focus mostly on rib fracture with chest wall pain but rarely differentiates ...
Would 45 Gy to the pelvis be sufficient for a locally advanced rectal cancer that has a complete metabolic response to TNT?
If you define the standard of care as what the vast majority of people do, the standard of care is to give 50.4 Gy in 28#, especially if nonoperative management is the goal. If surgery is part of the plan, we found that preoperative chemoradiation to 45 Gy followed by mesorectal excision resulted in...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
How do you counsel a young man receiving EBRT as part of TNT for rectal cancer about risk of infertility?
I counsel male patients that, although the testes are outside the target dose volume, they will receive enough radiation that it could, at least temporarily, impair their ability to conceive. I offer to refer them for sperm banking prior to starting treatment.
When treating with electrons, what is your approach to skin collimation to reduce penumbra next to structures such as the eye?
Skin surface shielding/collimation can be accomplished by a few methods. One is to create an impression of the patient and then conform thin sheets of lead/high density shielding material to this shape with an appropriate aperture for the target. This is time-consuming but preferable for small targe...
What is the best advice you received as a young attending?
Actually I heard this on the interview trail in 1997 from Sam Hellman: First be a good person. Then a good doctor. Then a good oncologist. Then a good radiation oncologist. In that order.
Would a high Decipher score affect your recommendation regarding the addition of ADT to XRT in a favorable intermediate risk prostate patient?
The simple answer is YES.To walk through why...1. Trials like RTOG 9408 demonstrate that there is a metastasis and OS benefit in Intermediate Risk disease from the addition of short-term ADT to RT.2. Later work from many groups showed that intermediate risk is a very heterogeneous cohort. This shoul...
When do you include the primary site in the radiation field for a penile cancer with negative margins?
Assuming he has had partial or total penectomy with negative margins, I don't treat the primary irrespective of nodal status. Control of the local disease is rarely a problem. From a radiation perspective, the battle is won or lost in the groin where an aggressive management approach is warranted fo...
How do you approach boost to the lumpectomy cavity AND 4 lymph nodes with extra-nodal extension when treating breast cancer with hypofractionation?
For breast/chest wall + RNI, I have transitioned to moderate hypofractionation giving 40 Gy/15 fractions. I don't see a clear role for standard fractionation; with 4+ nodes, the question is ALND but if you are giving RT, I'm not sure I see that as an indication for standard fractionation. Followi...
Do you hold nivolumab and ipilimumab when giving palliative radiation to abdominal targets?
This is similar to the question of whether you should hold bevacizumab for palliative radiation. You cannot really change the biologic effects of these agents immediately by holding them. The toxicity has been repeatedly shown to be minimal in trials where radiation has been included with concurrent...