Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Between KEYNOTE A-18 and INTERLACE, for which patients would you recommend using one protocol over another?
We currently favor A-18 for stage III disease (clinical or node-positive). A-18 had a more modern RT technique both for EBRT and brachytherapy while in INTERLACE, 60% had a prescription to point A for brachytherapy. In comparison with the EMBRACE 3D brachytherapy series, pelvic recurrence rate seems...
Do you consider ADT intensification with enzalutamide or abiraterone in patients receiving adjuvant radiation with ADT?
I agree with Dr. @Dr. First Last.One thing to note is ~3% of RADICALS, for example, included pT3b and high grade disease, and almost no patients in the ART vs SRT trials had N+ disease. Was largely GS7 and pT3a population and not the very high risk patients that select surgeons choose to operate on....
Does a high genomic risk score impact your radiation fields for patients with breast cancer?
There aren't prospective randomized data to support this, but I do use Oncotype to help me decide when to apply EORTC 22922 to offer RNI for medial, node-negative cancers. Although the trial was negative for its primary endpoint of overall survival, I a) find the absolute reduction in breast cancer ...
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...
With vaginal cuff brachytherapy, do you treat to the surface or a depth and why?
We prescribe to the surface of the vagina but also attend to the dose at depth. For patients receiving only vaginal cuff irradiation we use a prescription of 6 Gy VSD x 5 qod. Although this is a modest dose, it appears to be very effective in preventing vaginal recurrences, even in high-risk cases. ...
How would you approach a patient with prostate cancer with PSMA+ non-regional lymph nodes?
If we take the question at face value, this is a patient with de novo mHSPC and the treatment recommendation would be ADT (level 1) + ARPI (level 1) + RT to primary (level 1) and consideration of RT to metastatic sites (level 3 data).However, I would use one of the multiple PSMA-RADS-like scoring sy...
Is it appropriate to use a hypofractionated regimen to treat the pelvic nodes in prostate cancer?
Much of the world uses 60 Gy in 20 fractions as their new standard of care, which is endorsed by nearly all guidelines. When treating nodes people simply use 2.1 or 2.2 Gy per fraction to 42 to 44 Gy in 20 fractions simultaneously to the nodes. It is near identical to the 1.8 Gy to 45 Gy so not real...
In rectal cancer patients receiving total neoadjuvant therapy, do you prefer chemotherapy followed by long-course chemoradiation, or short-course RT followed by chemotherapy?
We now have level 1 evidence showing the superiority of a few TNT regimens over standard chemoradiation->surgery->chemotherapy for these patients. There are going to be some stage II/III patients where TNT is overtreatment (ie, may be able to avoid the chemotherapy, radiation or surgery), but that c...
Is it safe to use doses of 3Gy in a BID treatment for palliative urgent cases?
This combination of a "hypofractionationated" 3 Gy dose per fraction with a "hyperfractionated" BID schedule has been described in the setting of "quad shot" radiation- most typically associated with head and neck cancers. The goal is to provide robust palliation within a short time frame. The "quad...
Are the results of CONKO-007 changing practice for the management of pancreatic cancer?
The results of CONKO-007 are exactly as expected. The clinically relevant endpoint of OS was not improved with the addition of chemotherapy. These results are similar to the PREOPANC-2 trial in BRPC. Since definitions are rarely followed in practice, BRPC and LAPC populations have merged over time; ...