Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your approach to women with breast cancer who opts for a staged approach with up-front lumpectomy and SLN biopsy (pN-) when there are indications for adjuvant radiation therapy but she plans for a later mastectomy (=>6 months)?
That is not a common approach I have seen, and I would question the rationale of putting a patient through two surgeries when one can be done and forgo RT. If pN0, it would depend on what significant delay is, and I would extensively counsel the patient on recurrence risk should they end up forgoing...
How do your PMRT recommendations change with ITCs after neoadjuvant chemotherapy if they had SLNB only versus ALND in light of B51?
Data such as from Dana-Farber/Brigham and Women’s Cancer Center and the National Cancer Database (Wong et al., PMID 31228134), as well as the OPBC-05/ICARO study (Montagna et al., PMID 39509672), indicate that patients with isolated tumor cells in axillary nodes after neoadjuvant chemotherapy (ypN0i...
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...
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...
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...
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, ...
Can I treat breast nodal volumes with hypofractionation?
Yes. Published randomized trials have treated/reported 2,000 patients with doses of >2 Gy in hypofractionation vs standard fractionation trials with treatment to the axilla. Trials include Start A/B (513 patients), the old trial by Ragaz et al., PMID 15657341 (318 patients, hypox 37.5 Gy in 15 fx), ...
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
How do molecular and clinical factors guide personalized selection of HSRT dose fractionation regimens with bevacizumab in recurrent high-grade gliomas?
Multivariate analysis identifying HSRT dose fractionation, tumor grade, IDH mutation, and 1p/19q codeletion as significant predictors of progression-free survival (PFS) in recurrent high-grade glioma strongly supports a shift toward biomarker-driven stratification in future trials. These findings un...
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...