Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do TTFields work synergistically with SRS for patients with brain metastases?
Based on the presented data from the METIS trial, yes, TTFields works synergistically with SRS for patients with NSCLC brain metastases. It is not clear on the mechanism of action. It appears there is even greater synergy with use of ICI. One hypothesis is whether there is enhanced immune response, ...
Do you typically recommend placement of a rectal spacer prior to definitive radiotherapy, regardless of dose/fractionation?
In my opinion, the potential and role of rectal spacing in minimizing toxicity is not debated. The concern about spacing relates to risks of the procedure and its associated additional cost to treatment may be greater than the potential improvement in toxicity for the patient. As we continue to show...
Are there any scenarios in which you would offer SBRT as your preferred treatment approach for appropriate candidates with intermediate risk prostate cancer?
Based upon the PACE-B trial, 40 Gray to the prostate, 36.25 to the PTV, which was compared to standard or moderately hypofractionated radiation, and documented non-inferiority. It is reasonable to consider stereotactic radiation therapy as a standard of care for intermediate-risk prostate cancer. If...
How do you select which patients with H&N primary tumors benefit from proton therapy?
Surprising to see that the expert opinion after TORPEdO results is that IMPT is also a great choice. Granted, it contradicts the MDACC-led study, but we should have nuance and critical analyses.The rates of feeding tube dependence in the IMRT arm in the MDACC-led study are astronomical. I have never...
When do you consider using protons for breast cancer?
I think there is a limited role for protons in breast cancer outside of prospective studies at this time.With respect to partial breast irradiation, while initial trials showed some higher skin toxicities, modern institutional series have shown much better outcomes. That being said, the total number...
What is your preferred comprehensive nodal irradiation approach in non-metastatic breast cancer patients with underlying respiratory diseases or poor baseline respiratory function in light of the findings from the RadComp Trial?
The RadComp trial PRO-CTCAE item for no shortness of breath versus any shortness of breath significantly favored protons as reported in the abstract. However, after correction for multiplicity, this became non-significant, meaning there was no difference. While multiplicity analyses ensure that fals...
In a patient with pancreatic cancer who is heterozygous for the ATM c.875C>T (Pro292Leu) mutation with functional impairment in the gene product, is there any data or recommendation to support using SBRT vs. chemo-RT?
Ablative-dose radiation (100 Gy BED) is a curative option, with LC and OS similar to surgery. Everything else is palliative. 50 Gy in 5 fx with MRgRT is an evolving standard. The patient should be informed that this option is available at many centers. Otherwise, any palliative dose is fine. With th...
Do you add ADT to RT for a patient with intermediate-risk prostate cancer with discordant Decipher and ArteraAI results?
This will be a long response to try to provide transparency to these tests from what I know as a researcher and clinician. I also clinically see this situation frequently. We have made incredible progress in developing biomarkers in prostate cancer, but it is important to know that no single test is...
Do you use PAM50 LumB status to guide not just ADT use but also the decision to include elective pelvic nodal irradiation in patients receiving salvage RT after prostatectomy?
I think evidence for PAM50 as a predictive biomarker is becoming increasingly compelling, but I am not yet using it to determine either ADT use or to include (or withhold) pelvic nodal radiation in the salvage RT setting. At ASTRO 2025, NRG-GU006 provided prospective randomized evidence for PAM50 as...
Given the equivocal findings of NRG GI003, in which patients would you select for liver-directed proton therapy in the management of HCC?
Based on the results presented, there is not an indication to routinely recommend proton-based radiation for HCC. There are ongoing efforts to see if there is a subgroup that benefits from protons.