Questions discussed in this category
If ADT acts as a systemic treatment, we would have expected to see a benefit with an RP just like with radiation. Yet, this is not the case. What are ...
Meattini et al., PMID 39675376
The patient is a female in her 40s. No mucosal changes were evidenced on clinical exam. Chemo-RT is recommended by GynOnc at an academic center. ...
If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...
What are your volumes and dose/fractionation for external beam boost in lieu of tandem and ovoid or tandem and ring implant?
Are there specific AR Pathway inhibitors that can be crushed and used through feeding tube or would you just avoid ARPIs in such patients?
Are there any subgroups that would still benefit from RNI?
What dose and fields of treatment would you recommend?
Specifically, headaches thought not to be related to increased ICP.
How do you decide between ureteral stent and percutaneous nephrostomy for decompression?
Would you consider omitting local therapy?
E.g., patients with small CNS mets without vasogenic edema or symptoms. Epidural disease without epidural spinal cord compression or asymptomatic low-...
One particular circumstance involved detecting a ROS1 fusion upon the metastatic recurrence. Is this pneumonitis risk seen with osimertinib alon...
If you recommend or use induction chemotherapy, what is your preferred chemotherapy regimen?
With low #s of patients on the durvalumab PACIFIC trial with EGFR mutated disease, and LAURA trial design of osimertinib until progression, should we ...
What do you think is the role of radiation for this patient and how should it be timed?
If a patient is considered high risk for surgery, with another primary cancer (HCC) and has an incidental renal finding that is highly suspicious for ...
Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.
For example, if MRI revealed prostate-confined disease but PSMA had moderate avidity in the bilateral seminal vesicles, would you obtain further biops...
If so, what do you typically prescribe?
How does time since radiation, original PSA and grade group/gleason score inform your decision?
Is there objective evidence demonstrating a benefit of consolidative durvalumab or prophylactic cranial irradiation in patients with stage I small cel...
If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...
Do you offer observation for POLE mutated tumors?
Would you consider adding docetaxel to ADT and novel hormonal agents?
For example, a large iliac or sacral plasmacytoma causing symptoms. Both medical oncologists and radiation oncologists get nervous about RT-related cy...
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g., skin can...
FDG PET, Axumin PET, Bone scan? Or just proceed with salvage ADT/RT?
How do factors such as the stability of the bleed, tumor histology, and patient condition influence your decision?
Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?
Would you consider the addition of carboplatin/paclitaxel + dostarlimab to radiation as opposed to radiation alone?
Would you offer definitive radiation/chemoradiation if he is refusing cystectomy?
Do you prefer upfront cisplatin/etoposide for 2 cycles, then 50 Gy with ENI, then resection, or induction chemo followed by definitive chemoradiation?...
Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy.
Is there compelling reason to start PMRT prior...
Would you consider this stage IVA (spread to adjacent organ) or IVB (spread to distant organ)? For instance, would the presence of direct lumbar verte...
Would you recommend concurrent chemoradiation or targeted therapy with lorlatinib?
My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...
How do you advise patients who strongly desire chemotherapy?
Are there other settings where MRI is used for nerve assessment and radiation planning such as for certain definitive RT cases?
Would you offer chemotherapy after radiation is completed?
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
Al-Ibraheem et al., PMID 33731050
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
Would you hypofractionate or be more conservative at 2 Gy per fraction? Would your management be affected knowing the patient is on hydroxyurea?
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...
Is there data on neoadjuvant chemo-RT or chemo in this setting?
NCCN states that all operable NSCLC patients should be evaluated for pre-op therapy with strong consideration of nivolumab + chemotherapy for those wi...
Some consider T4N3 Stage IIIC to be a borderline case. None of these patients were included in either PACIFIC or KEYNOTE-024 for example. Would y...
Assume the patient is young and active.
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
Cervical cancer FIGO stage IIIC2. Bloodwork shows elevated ESR and CRP.
The patient has extensive disease, and requires palliative radiation to the scapular area (proximal to the brachial plexus) in a region overlapping wi...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
Do you start neoadjuvantly? Concurrently?
Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...
Would you offer radiation and chemotherapy, vorasidenib, or observation?
The patient has an asymptomatic metastasis in the left atrial appendage.
Would you start off with immunotherapy then add radiation later, or visa ver...
Are there any recent publications or resources regarding which immunotherapy agents are contra-indicated with the use of RT or that outline interactio...
Do you perform NGS on all specimens? If so, how much do you rely on that alone to determine clonality?
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
Would you continue it until progression of disease? Or would you switch immediately to next line systemic therapy?
Any pitfalls to be aware of?
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
Would chemoRT be preferred over surgery if there is LVI or PNI?
The NCCN lists concurrent chemoradiotherapy as a primary treatment option in these patients. If so, what total dose do you deliver to involved ly...
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
Or do you start with systemic therapy and then reassess?
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
Is there data supporting the idea that chemotherapy must be onboard prior to delivering radiation for maximal radiosensitization (particularly for hea...
STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though.
For patients staged only with PET that is widely M1, should a CT ...
Would treatment be palliative (i.e. for ureteral obstruction) or definitive? Is there a role for chemotherapy or hypofractionation/SBRT?
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
How do the results affect your recommendations for workup and management?
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
The 4 cm cuff recurrence occurred 3 years after definitive treatment with hysterectomy and vaginal cuff brachytherapy to 21 Gy. The recurrence had a c...
Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...
Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
For example, do you favor using different induction chemotherapy (gemcitabine/cisplatin or TPF) for endemic vs non-endemic disease?
Do you favor usin...
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
Given that LU002 has failed to meet its progression free survival benefit in results presented at ASCO, will you offer consolidative radiotherapy for ...
If using adjuvant chemotherapy, should the patient receive carboplatin or use a more intensive regimen because of the positive margin status?
Would you recommend post operative radiation in an adult patient with a thoracic spine osteosarcoma?
S/P neoadjuvant chemotherapy and followed by oncologic surgical resection but with positive margins.
Why does this differ when treating extracranial sites (lung, pelvis) where we hold bevacizumab prior to RT?
If so, when and to what extent?
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b
In light of the 4/2024 JCO publication by Peng et al., PMID 38215354
Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
Patient has multiple adverse features on pathology, however, PSA just became detectable one year after surgery. SPPORT included patients with PSA>0...
Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?
Would you ever consider this approach for an initially polymetastatic patient?
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
If so, do you modify your external beam dose?
How do we approach patients with rare tumors given the paucity of data?
What is the role of adjuvant radiation therapy for stage III melanoma in the era of adjuvant Opdivo?
Burnmeister data from 2012 showed a local control benefit for radiation therapy in selected patients, but that was without immunotherapy. Is adjuvant ...
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
Is there a role for adjuvant chemotherapy or radiation?
Would you consider radiation following surgical resection of an intramedullary benign nerve sheath tumor with a small amount of residual tumor (9 mm) ...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?
Do you consider dose escalating to 160 mg or do you add chemotherapy to osimertinib?
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
Are there other measures, pharmocologic or adjunctive, that can be used or are under investigation to mitigate cardiotoxicity related to chemo- or rad...
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
Which patients specifically benefit from both mpMRI and PET-PSMA?
Is T4 disease a contraindication?
If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...
Would you offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?
Does the site of treatment factor into your decision?
Do you recommend adjuvant chemotherapy after radiation treatment?
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
If so, would you recommend adjuvant chemotherapy and PCI after?
How would it change your risk group or management? Does Decipher help further inform treatment?
Specifically, do you offer closer follow-up for certain patients after local radiation?
Many options for vasomotor symptoms of menopause do not work well for men on ADT. However, fezolinetant is a neurokinin B blocker, so theoretically, s...
Have you been able to deliver standard of care treatment?
I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...
With the recent publication in IJROBP showing a greater than 50% response rate, have you started integrating this into your practice?
For radiation oncologists, how do you ameliorate the risk for radiation-related injury to epicardial coronaries during treatment sessions?
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
What factors might play into this decision?
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
What would you recommend for a patient in their 60s with stage IB grade 1 endometrial cancer without LVSI? How would this differ for a patient with st...
Do you proceed with sequential, concurrent, or sandwich treatment?
What is the harm of waiting for another recurrence after a second GTR to delay the toxicity of radiation and chemotherapy? The patient is a woman <...
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
Especially as the study was done before the adoption of total neoadjuvant therapy
Has this recent retrospective analysis published in Lancet Oncology changed your practice?
Is there benefit to radiation on top of systemic therapy?
How does margin positive influence your decision?
Do you preferentially use Ra-223 first given the RALU study?
In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness:
Is a whole spine MRI in...
If so, what would be your approach to radiation? Could SBRT be an option?
Does tumor size, age, or performance status play a role in your decision-making?
Example: in a patient with a non-resectable pelvic mass involving the vagina but without evidence of distant disease, would you favor pelvic RT (as on...
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
Do anticipated fields affect whether extractions are required i.e., limited field glottic larynx could forego?
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
How will you translate treatment recommendations from older studies to the new staging system?
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...
Can chemoradiation be curative without maximal debulking TURBT?
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
Do all patients with brain metastases get started on anticonvulsants?
Do you decide based on extent of edema, tumor size, or something else?&nb...
The patient's current PET scan showed no systemic disease. Due to his age, there is a concern of whether the patient would tolerate dual immunotherapy...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
Severe lymphopenia can develop during treatment and increase the risk of Candida/HSV superinfection, along with potential challenges for any procedure...
Does the presence of parametrial or cervical involvement impact your decision?
How do you sequence treatment modalities?
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
What workup do you typically recommend?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
How would you integrate RT with molecular agents?
Consider treatment of stage IVB cervical cancer with systemic therapy and local pelvic radiation therapy as in Perkins et al., PMID 31810653.
Do you feel comfortable stopped abiraterone after 2 years?
After initial induction chemo, how do you choose between radiation alone or concurrent CRT?
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
How do you decide when to “pull the trigger” in these cases where the growth trajectory is slow?
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Is it necessary to delay the start of radiation therapy for males planning on sperm banking for fertility preservation?
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
How do you pursue fertility preservation in younger females with this presentation?
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
Considering this is stage IV disease, do your recommendations for definitive or adjuvant treatment (after surgery) change?
What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...
Is there any role for RAI?
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
If so, which checkpoint inhibitor would you use?
What XRT dose do you use? Does the location of the disease (e.g., mediastinum) affect your decision when taking toxicity into account? would you offer...
Do you also give neoadjuvant, concurrent, and adjuvant ADT in the same manner as for non-SBRT EBRT?
Staging/pre-op MRI only showed mild non-specific thickening.
For example, initial imaging shows numerous bilateral nodal mets extending into the low neck but after induction gem/cis, originally involved nodes ar...
Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...
Considering the ASTRO guidelines recommend against systemic therapy for patients with FIGO stage I-II endometrioid adenocarcinoma, would your recommen...
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
MRI pelvis shows a 3.5 cm primary that appears infiltrative and without clear parametrial extension on MRI. Staging PET negative.
Is there any ...
Taking into account follow up from NEO, OPERA and other organ preservation trials?
Please comment on toxicity profiles and the insufficient evidence regarding overall survival.
If using cetuximab, would you recommend accelerated fractionation?
In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
If so, how long are they on degarelix before the switch?
Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...
Please specify how your institution is allocating resources now or will be soon.
Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?
Do you base your decision on extent of residual disease?
Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...
Is a placebo-controlled trial anticipated?
What is your approach to try to persuade her that photons would be a better option?
Are you waiting until drug availability or changing to a preferred non-cisplatin radiosensitizer? If you're utilizing an alternative to cisplatin, wha...
Would you biopsy lymph node to confirm recurrence/histology?
If confirmed, how do you decide between RT vs chemotherapy? If chemo - BEP x3 vs E...
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
If you do not use the PORTEC-3 regimen for p53 mutated IA endometrial cancer, what specific protocol or combination of chemotherapy and radiation ther...
If ADT +/- ARPI + RT, what duration of systemic therapy do you recommend?
Assume the patient is not a candidate for surgery. What dose would you use? Would you recommend a lower dose to not damage the patient's kidney functi...
How would you add radiation in your treatment paradigm? No clinical trials available due to age.
How do you take into account pathologic factors like %clear cell histology, myometrial invasion, and LVSI?
I.e. based on the findings of ADAURA in surgically managed patients.
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
Lately I have seen patients with a concurrent gynecologic (requiring chemoRT), head and neck (requiring surgery), and early stage NSCLC (requiring SBR...
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
If the patient had no nodal sampling, would this influence your decision?
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
Would you consider these as metastatic sites? Would you biopsy to confirm?
Is your approach different than that to a primary essential tremor?
History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...
Are you more likely to consider a trans-anal resection?
How can these interactions be improved?
When would you use 5-fluorouracil instead of, or in addition to, cisplatin during chemoradiation? When, if ever, would you offer adjuvant hysterectomy...
There is evidence that parents do not adequately understand the purpose of phase I pediatric cancer trials (Cousino et al., PMID 23071225).
Is radiation effective in this case and if so, what dose would you use? Is there potential for perforation?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Reference: TROG 05.01 Trial
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
How does your approach differ for patients under age 60, between 60-70, and over age 70?
And, for additional information, what are the differences in 5 year survival and disease specific survival for stage I NSCCA between lobectomy vs SBRT...
Do you have a number/volume threshold for SRS vs WBRT?
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...
The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...
The patient presented with spinal cord compression, had subtotal resection and instrumentation with metallic hardware. Main concern is that post op su...
Would you consider empiric SRS if biopsy/resection is not feasible?
When would you consider liquid biopsy?
How does histology and/or molecular testing change your approach? How does the length of the disease free interval change your approach?
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
Is there data on efficacy or toxicity when chemotherapy is added to Proton beam therapy for head and neck cancer like there is data to support adding ...
According to the NCCN guidelines, there is a highly selected group of T4a glottic larynx patients that can undergo observation instead of postoperativ...
Encouraging aggressive PO intake in patients with swallowing dysfunction may place them at risk for aspiration pneumonia, especially risky if undergoi...
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
PSMA PET vs Conventional imaging vs combined imaging?
How is your approach different from or similar to those who undergo surgical menopause?
What is your preferred dose/fractionation following a previous course of radiotherapy?
No evidence of distant disease elsewhere. Surgical resection is not possible. Would you recommend metastasis direct therapy to the liver (i.e. SBRT or...
In light of recent trials showing no difference in outcomes with RT+cetuximab vs RT+IO, does this potentially lead us to use immunotherapy in cisplati...
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
NGS without any actionable mutations and PD-L1 TPS 15%.
Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?
Is this stage IS or IIA? Is chemotherapy or RT preferred?
If considering systemic therapy, would you consider standard chemotherapy or use biomarker-directed therapy (e.g., imatinib if ckit+, larotrectinib/en...
How do you decide between downstaging chemotherapy or upfront concurrent chemoradiotherapy? Both are listed as NCCN options.
Would you favor the use of any particular biologics over others?
How would you treat such a patient?
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
General recommendations on dose and management presuming unresectable.
Traditionally these patients may have received chemotherapy prior to chemoRT.
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
What is the potential risk of immunotherapy toxicity in combining palliative RT in a patient already on immunotherapy?
Any adjustments in terms of elective nodal coverage?
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
Should the dose still be given after completion of RT?
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Would you treat with ADT if no metastatic disease?
Does absolute PSA (e.g. PSA<2) inform decision?
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
Does ADT affect the results of a biopsy?
Louis et al., PMID 34185076
Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT.
What treatment margins/set-up/on-board imaging would you use?
If radiation is indicated, what dose would you use?
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase II...
If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
Would you offer adjuvant radiation? (Dose? Target?) vs Salvage?
Would you add ADT? Would you add abiraterone?
Would the number of lymph nodes involv...
What precautions can be taken to limit infestation of the department?
Do you implement a treatment delay and if so how do you decide when...
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
How often are you scanning the brain and what is your trigger to treat?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
Is prior Ra-223 a contraindication for treatment?
Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?
If you do recommend adjuvant therapy, what regimen would you use?
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...
Do you have a preference for bicalutamide? Can abiraterone be used instead?
What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...
At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value?
What imaging modality would you ...
Would you use it for initial staging or at time of biochemical recurrence?
If radiation, what type? EBRT or brachytherapy? Any other techniques you would recommend, such as rectal balloon?
The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs. Would pattern of spread affect your d...
Stage is cT4N2M0.
Weekly (20 mg/m2 D1, D2) and q 3 wks (70 mg/m2 x 3c or 100 mg/m2 x 3c) regimens have all been listed as acceptable. For reference, RTOG 97&...
Assuming no overlap with prior RT doses, would a history of necrosis cause you to hypofractionate rather than deliver single fraction SRS?
Is it reasonable to dose de-escalate since survival will likely depend on the metastatic lung cancer?
Would you consider boosting the nodes? What dose? Would this change your recommendation for length of ADT?
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Are you offering patients beta-emitters (Samarium-153 lexidronam, strontium-89) to any patients?
Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?
40 yo adult patient with a~6cm mass with concern for skull base bony involvement (group III and stage III, no nodal involvement )
Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out.
Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Resected small bilateral tonsil SCC & base of tongue SCC.
The patient received 6 cycles of BEP 30 years ago for testicular cancer, and suffers fr...
Has your practice changed based on the randomized, phase 3 study showing prophylactic gabapentin is not effective?
Please share your thoughts and exp...
What about for a patient with complete radiographic response who declines surgical management?
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
Does severity of dementia play a factor in recommending ADT?
In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?
Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...
Would you do consolidation radiation or active surveillance?
Would presence of variant histology change your recommendation?
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...
If so, when do you consider this?
What would be the treatment duration if using oral TKI?
What clinical criteria would make you prefer TORS as the initial treatment approach?
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
How do you stage? Like nasopharynx or p16+ oropharynx?
Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...
Do you try to keep Hb> 10 or 12? Or somewhere in between?
What would be your radiation volumes/dose and choice of chemotherapy?
E.g. disease burden causing airway or vascular compression.
Are there other high or very high risk features that would also contribute to your decision making?
CNS recurrence occurred within two years of prior neoadjuvant therapy
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
NSABP B51 and B52 specifically prohibit this.
Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?
Would you offer adjuvant RT or chemotherapy? If so, what chemotherapy would you prefer?
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
Patient previously had prostatectomy and salvage RT
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
Any role for surgical extirpation vs systemic treatment?
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...
Does patient age effect your approach?
Would you consider RPLND for any patients in light of the phase II SEMS trial presented at the 2021 ASCO GU Ca...
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
Patient is <60 years old
Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...
Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?Does IDH status change your treatment approac...
Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?
Length of temozolomide course when given with adjuvant radiotherapy
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
https://pubmed.ncbi.nlm.nih.gov/34077237/
What doses and constraints do you use?
If a patient has a large femoral metastasis that cannot be resected, but is to be stabilized with ORIF which will push tumor into the distal end of th...
Is there any role of radiation therapy for these patient for symptomatic relief?
Performance status is excellent. Second surgical opinion has also confirmed need for amputation, as the recurrence is now breaching intra and extra ar...
History of CDH1 mutation and prophylactic gastrectomy in 2017 - no other primary site found beyond vagina at diagnosis.
Vaginal tumor completely resp...
Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...
Gleason 4+3=7 and PSA 4
Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.
This patient had resection of the primary, requiring multiple resections to obtain an R0 resection, followed by adjuvant radiation to the primary. The...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
Are there other adverse features aside from seminal vesicle invasion, positive margins, or extraprostatic extension that you consider?
Would you radiate? Surgery? Chemo? Follow with short interval scans?
How would size of adenopathy (e.g. <2cm vs larger) and time of recurrence (wi...
Patient did not previously receive para-aortic radiation. Considering RT vs RT + chemo vs chemo alone
Are there any effective non-pharm or pharm interventions?
Is chemoradiation a viable strategy in osteosarcoma?
Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...
Would you consider induction: TPF vs cis/gem or would you proceed with chemoradiation with cis/RT and consider adjuvant cis/5FU?
Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.
Recurrence picked up incidentally on CT. No germ line mutations, somatic tumor testing of node resulted negative.
PET confirmed isolated recurrence
Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...
The site of oligometastatic disease was to a supra-clavicular node and was biopsy proven.
Would you consider SBRT and continue osimertinib?
Is there a subset of patients you would avoid neoadjuvant CRT and operate first?
This patient had a Ki67 of 27%. However, the inclusion criteria for the NETTER-1 Trial was Ki67<20%. Would Lutathera be an option if labs are withi...
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...
What clinicopathological features would need to be present for you to recommend adjuvant chemotherapy? Would you treat pT3 disease? Any specific histo...
Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...
Would you consider doing a pre-op RT prior to possible re-excision? If yes, what dose would you give? If the location is between L4-L5 spine.
In particular, for frail patients to avoid toxicity or for those that do not want chemotherapy
If so, do you allow a period of "washout" between immunotherapy and radiation?
Assuming all other factors are favorable (pT1-2, TME, negative margins).
Is there a threshold of when you would use chemo/radiation?
Is it essential to wait one week after loading dose of erbitux to start RT for head and neck cancer?
In the post-op setting, would you delay 1 week even if it took them out of the 6 weeks post-op window? Meaning the loading dose of erbitux was given d...
i.e. 1/1 node with ECE
Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?
In primary surgical resection, ENE on surgical path would be indication to add adjuvant chemoradiation. After progression through definitive chemoradi...
Is the short time to recurrence a reason to not consider definitive management with surgery/radiation?
Should systemic therapy be added if pursuing d...
How does dialysis affect PSA lab values?
How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...
Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...
If advanced stage do you follow same guidelines as Scc? Do you use same Cth regimen? Role of total laryngectomy ?
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
Would you add abiraterone or enzalutamide?
I know many centers are exercising extra precautions in light of the new concerns with coronavirus. How are people explaining things to their patients...
Have the RAPID or CALGB 5064 studies changed your treatment approach?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
If post-op with clear margins would you prefer adjuvant RT or close observation with surgery for optimal reduction of local recurrence? This particula...
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
If so, what is your time threshold for when you'll start PCP prophylaxis--when you anticipate steroid courses greater than 1 week? 1 month? 3 months?&...
Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...
Does not technically meet high intermediate risk criteria.
If on pembrolizumab or nivolumab, when would you escalate to ipilimumab/nivolumab?
ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.
What is the risk of perforation / fistulization?
Would gross ENE or R1 resection trigger you to consider adding chemo? If so, do you use weekly cisplatin or cisplatin/etoposide?
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy.
NCCN recommends either ISRT with rituximab/chemotherapy or ISRT alone in this scenario. What factors help your decision making?
Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?
Which Radiation modality, if any, would be preferred?
Typical chemotherapy does not work for SFT. In which circumstance would you use VEGF ( Temozolo...
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
Are you employing more or less primary chemoRT v. surgery for some cancers? Are you dose de-escalating? What are issues radiation oncologists should b...
The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.
Both ARTIST and Inte...
Would you offer SBRT to both sites, SBRT to the primary and standard fractionation to the node due to proximity to the main bronchus/proximal lobar br...
Would it matter the site of recurrence (ie lung nodule vs bone lesion)?
After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...
How do you decide on other chemo regimen? (Dosing, frequency, carboplatin based, non-platinum based etc.)
Would you use Cetuximab?
Altered fractiona...
Presented with mass projecting into right/left anterior ethmoid complex
What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...
Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...
Ie for patients who are inoperable due to comorbidities?
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...
Would you consider this refractory disease and go on to salvage regimen and auto-SCT, or is there a role for definitive XRT to the site of residual di...
The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?
>5cm. If so, what is your preferred regimen?
If neurologic symptoms are absent or controlled, does that affect your treatment decision?
MRI? Endoscopy? Physical exam?
Is there evidence for radiation therapy in this setting?
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
What is the added benefit of Chemo-RT vs RT alone?
How does your approach differ for patients with stage IIA versus IIB disease? Age?
If so, would you consider it with monotherapy only or also with combined checkpoint blockade?
I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...
Is there data to support every 3 week dosage v. weekly?
https://ascopost.com/news/march-2022/postoperative-weekly-vs-every-3-week-cisplatin-i...
What dose of radiation, what type of chemo, and what indications?
For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...
Would you consider the addition of chemotherapy to proton beam therapy?
This has been a common practice in the community. Is there a benefit for certain patients?
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
Do different modalities of imaging (PET vs MRI vs CT) help you to distinguish one etiology versus the others? What about other clinical characteristic...
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...
Aside from smoking cessation, what interventions have you found useful to manage patients with chronic symptomatic laryngeal edema? Steroids seem to b...
How are you modifying your current sarcoma-directed therapy in the setting of the COVID-19 pandemic?
For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?
Should staging and treatment decisions be made based on imaging alone?
Acknowledging that there is no time for good trials yet in this setting
How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...
Would your practice vary based on hormone receptor or Her2 status?
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
Mitigating the spread of COVID-19 is of utmost priority now that containment measures have failed. Social distancing will help "flatten the curve" of ...
Is there specific workup you perform? Are there preventive measures? Once established, are there non-pharmacological and pharmacological treatments yo...
Assuming the patient is not a candidate for SRS
How would a much higher risk cancer affect decision making? How would you treat him?
Specifically with reference to rural settings where the logistics of early in the week delivery may be more challenging.
Our medical oncology team wants to give a patient Vitamin B12 and Folate 1 week before chemo- do we need to push back the RT start date to start both ...
This question has come up most frequently with respect to the flu vaccine recently. Also, frequently this has been asked about the shingles vaccine an...
Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...
Would your choice of concurrent chemotherapy be impacted by this histologic finding?
In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...
i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...
The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...
-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX.
-Given that this is standa...
For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...
Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...
Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?
Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?
The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.
Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?
Specifically concurrent ifosfamide? Induction AIM?
How long would you continue androgen deprivation after radiation?
Would PDL-1 status impact your decision?
Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?
Should cystectomy remain standard of care?
(Recently debated in JAMA Oncology:
http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
I understand the perioperative trials are not based on tumor regression in cancer cells.
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial.Antonia et al., PMID 28885881...
Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on enzalutamide and leuprolide and refuses docetaxe...
For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?
Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?
CT or PET? If so, how often?
Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...
Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?
What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...
Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.
https://www.nejm.org/doi/full/10.1056/NEJMoa1813181
Is IO related pneumonitis in the radiation field or more diffuse?
Some ENTs advocate for a neck dissection as a way to avoid chemotherapy if there is a high chance there is no ECE. This is without removing the primar...
Would you proceed with induction chemotherapy (eg TPF or cis/gem) to downstage or neoadjuvant chemoRT? Would your approach be different if there is or...
Do you feel it is important to start durvalumab within 14 days of completing cCRT? What real life challenges do you face in doing so and wh...
Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes? Do you utilize EBRT?
Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...
Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...
Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...
If so, how would you modify this regimen?
If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?
For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...
The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...
Is there a role for SBRT with or without the addition of systemic therapy?
What features would make you more likely to recommend radiation therapy with chemotherapy?
No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.
Do your recommendations differ if patients are pre or postmenopausal given the data?
There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...
Do you ever start radiation +/- 24-48 hrs from C1D1 for chemotherapy due to logistical barriers?
Do you prefer chemotherapy to start at beginning of ...
Which appetite stimulants are the most effective? How do you respond to patients who request medical marijuana?
Hormonal therapy would not be tamoxifen.
Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...
Is concurrent chemotherapy necessary for these patients?
Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...
Does papillary histology influence your decisions regarding surgery, chemo, radiation dose or nodal coverage?
For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...
If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...
Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...
Routinely? Only with oropharyngeal cancer etc.? Given that low expression of EGFR subset did better, do you believe there is a true benefit in cetuxim...
Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...
Or do you wait for platinum resistance?
If so how would you select patients (ie. PS, histology, PD-L1 expression level)?
For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...
Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...
Would you use the same schedule as early stage NSCLC primary?
The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...
Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?
Would this be any different for whole brain radiotherapy?
Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?
A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...
Are these patients better candidates for preop chemotherapy alone?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
In the context of the new staging systems and possible differences of HPV mediated vs smoking mediated oropharynx SCC, would you ever not recommend co...
By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...
Current NCCN guidelines seem to support a variety of approaches.
If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?
Is there any data on safety of radiaiton with pertuzumab?
These patients have been largely excluded from these trials. What if the infection is well controlled?
Do you refer all patients who are felt to be at high risk to a genetic counselor for testing or are you comfortable performing a MyRisk panel in your ...
If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...
What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?
Obviously the details matter a lot, but are there guiding tenets one should follow beyond expressing condolences to the family?
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
Would you recommend radiation and/or systemic therapy? If you would irradiate, what would your fields/volumes look like?
For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...
If so, what regimen would you consider?
Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?
How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...
The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...
What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
If so, how do you manage counseling for someone with low health literacy?
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.
Do you offer neoadjuvant RT with resection and node dissection vs. definitive radiation? How extensive does the nodal disease have to be for you...
In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?
What dose and volumes would you use?
Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
Is there any role for a trageted agent with CNS penetration (such as second generation ALK inhibitors) after completion of postoperative brain radiati...
If not, what is your thyroid hormone withdrawal protocol? If so, would you still treat a patient with possibly metastatic disease?
Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?
In a patient who already received 13 courses of radiation (with complete response), is there any other effective treatment?
In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...
To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?
Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...
Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...
If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?
Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...
For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well.
How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?
Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...
Would your recommendations change if it was a partial vs complete radiographic response?
Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?
How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?
Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...
In the setting of recent craniotomy and a plan for SRS to the surgical cavity, which systemic therapy would you choose and when would you start it?
The immediate response by patients in this situation seems almost universally to be, "But I'll starve to death!" Referencing literature about lack of ...
For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...
Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost. Does the cost-effectiveness fa...
This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?
Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724
In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?
Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
Does the site of palliative radiation therapy matter (i.e. femur, abdomen, pelvis vs base of skull)? How long should you wait to give palliative ...
The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.
Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...
What about patients who are still on steroids for radiation pneumonitis?
Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...
What do you consider when making this decision (concurrent chemotherapy, amount of bone marrow in field, whether patient is already on antibiotics, et...
Does your recommendation change depending on the agents they received?
Do other factors (i.e. Gleason score, pretreatment PSA, or pT stage) affect your decision?
If so, when? Although anemia is associated with worse local control in HN cancer, I don't know of any data that shows that blood transfusions can help...
Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...
Do you have a preference for specific steroids? Some practices may switch to prednisone during this time.
Patients with gliomas are often on d...
Are there specific subsets for whom these results should change management?
In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...
In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...
Assuming the patient is a candidate for either of these treatments?
If so, what is your preferred regimen?
We have a great palliative care clinic and I like to refer many patients with metastatic disease, even if I feel that they will live a year or two lon...
Is there any consensus regarding the optimal RT dose, fractionation, and timing to the best abscopal response? What is the optimal metastatic site to ...
If the systemic agent is going to be held, how many days prior to starting radiation therapy should the agent be held and when can it be restarted aft...
If a patient had a recurrence that was pathologically proven despite negative idodine scans, what imaging scans would you follow up with for surveilla...
In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...
As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?
The NCCN guidelines discourage the use of PET/CT surveillance but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...
Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...
What are the targets (tumor bed, positive margin, nodes etc.)?
What dose do you recommend?
I know that some would argue that healthy patients with an excellent performance status may not need an early palliative care referral, but wouldn't i...
In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...
Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.
Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...
If so, what would you include in the target and what dose?
Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
Are there any open clinical trials testing this?
Our ENT surgeons often tell patients with evidence of matted nodes on imaging that their swallowing function will be much worse after 70Gy as compared...
Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?
I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...
Definitive chemoradiation vs. surgery followed by adjuvant radiation/chemoradiation?
Even though we do not have the best data on the use of induction chemotherapy, what are current practices?
Is your practice different between HPV+ an...
Is there a consensus on the MAGIC v. MacDonald debate?
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