Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What do you tell patients that opt for High-intensity focused ultrasound (HIFU) for favorable intermediate risk prostate cancer over AS (Active Surveillance), RP (Radical Prostatectomy), EBRT (External Beam Radiation Therapy), or brachy?
There are currently no published trials that specifically address this question, which is a very good one.My general discussion is that ablation therapies (not specifically HIFU) will have less negative impact on quality of life factors such as preserving erectile function, avoiding urinary incontin...
Are CHEK2 mutations a contraindication for breast conservation therapy with lumpectomy + RT?
Among women with early-stage breast cancer and moderate penetrance breast cancer susceptibility genes, such as CHEK2, decisions about breast surgery are largely based upon personal preferences. According to data from large population-based studies, women with CHEK2 pathogenic variants have about a 2...
Do you offer adjuvant osimertinib to EGFR exon 19 deleted patients with T2N0 NSCLC treated with definitive SBRT?
Given the fairly striking benefit of ADAURA in resected patients, there likely would be a locoregional and distant control and likely survival benefit to this approach but we don't have data to support this. PACIFIC-4 is currently enrolling. Study of durvalumab vs placebo in patients with early stag...
Has the HYDRA study of hypofractionated radiation, and its discussion in the 2026 NCCN guidelines for prostate cancer, changed your approach to moderate hypofractionation in either prostate-only or prostate and pelvic node radiation?
Very few of us can gain substantial wealth by giving 8 more fractions to prostate cancer. I certainly can't earn more by simply giving 28 or even 45 fractions or a 100 fx. The vast majority of us are now employed, and based on median RVU stats, a minority of us even reach a threshold to bonus or eve...
How do you manage moderate chest wall pain after breast radiation if imaging studies are normal?
Pain in the breast or chest wall due to RT-induced myositis or fibrosis is generally mild and responds to nonsteroidal anti-inflammatory agents and stretching exercises. However, one should first determine whether there is a cause of pain separate from RT effects. One of the common sources of such c...
Is there any role for ctDNA testing after surgery or SBRT for Stage IB NSCLC to determine the need for adjuvant chemotherapy?
This is another emerging use for ctDNA that has shown promising results in small studies. The TRACERx consortium in the UK looked at the evolution of early NSCLC over time in 100 patients who underwent resection. They performed multi-region sampling and whole-exome sequencing and created patient-spe...
Do you use either memantine or hippocampal sparing technique to preserve cognitive function when giving whole brain radiotherapy?
Dr. @Dr. First Last and I put together the response below:We use memantine and hippocampal sparing technique for all brain metastasis patients who are planning to receive WBRT. This is based off the recently published phase III trial NRG CC001 that found hippocampal avoidance WBRT plus memantine res...
Is there a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?
Excellent question. There is certainly a need! If we step back and take an honest look at our control rates with SBRT, while primary tumor control rates are high, we suffer the same viciousness of lung cancer that surgeons do - local control is trumped by a 2-3x rate of regional and distant failure....
What additional work up would you do for a T1bN2 squamous cell carcinoma of the true larynx if endoscopy demonstrates a true cord lesion extending to the commissure with normal mobility and no evidence of supra or subglottic extension?
I assume that PET-CT was performed and demonstrated only the neck and the laryngeal lesion. The histology of VC cancer is usually well-differentiated. I would examine a needle biopsy of the nodes for discrepancy in histology and stain for p16 for the possibility of a second, unknown primary, which t...
Is long term ADT now the standard of care with salvage prostate bed RT?
The dreaded hormone question...After 40 years of embarking on extremely well designed randomized trials, we still are confused about the who, what, when of ADT. Will RTOG 9601 create a new care standard? As @Dr. First Last said, I think we will see increased utilization. I have been using bicalutami...