Medical Oncology

Questions to ask your oncologist

What is important that you know when considering your options for anticancer treatments?

When it comes to cancer treatments, there is no single best way that is appropriate for all patients.  Making the right decision about treatments such as chemotherapy, biological treatments, and radiation therapy requires having enough information to weigh up your options. For most people, this is a new situation and they and their family members often don’t know what information is needed to make an informed decision or how to give informed consent to proceed with a treatment plan.

To ensure that you have the information that you need, these are some of the important questions to ask your oncologist about any proposed treatment:


• What type of therapy is this and what demands is it going to make on me and my family?

• Is this a widely used treatment that is recommended by international authorities or professional guidelines?

• What is the likelihood that this treatment will make me feel better or help me to live longer?

• If the treatment helps, when should I start to feel better?


What is the best that I can expect if this treatment works well?

• On average, how much does this treatment help patients to live longer?

• If the treatment does not help me to live longer, can it make me feel better and improve

my quality of life?

• How often does this treatment help patients?

• If it does help, for how long is it likely to help?

Potential risks:

• What side effects am I likely to suffer if I take this treatment? How severe are they likely

to be and how long will they last?

• Can the side effects be prevented?

• Are any side effects potentially dangerous? If so, how often do they happen? What can

be done to minimize my risk from them? Are they reversible?

Are there other options that I could reasonably consider?

  • More aggressive therapies?
  • Less aggressive therapies?
  • Experimental therapies?
  • Complementary or alternative therapies?
  • Symptom control without anticancer therapies?

It is important to participate in the decision-making process and always have all the information related to the treatment that you’re undergoing.

Getting a second opinion from a second specialist is a good option to gather more information about the treatment options and for your peace of mind.

Medical Oncology

Why should you get a second opinion on your cancer diagnosis?

An oncological diagnosis is a life-changing diagnosis that requires fast and adequate decisions.

You want to have confidence that out of the many treatment options available nowadays, you are getting the best one for your diagnosis and you.

Getting a second opinion may help you make a more informed decision about your cancer treatment. It may also introduce you to advanced treatment options if they are available for your cancer type and stage.

Here are some of the reasons why you should get a second opinion on your cancer diagnosis:


Getting a second opinion will give you the confidence that you are getting the best treatment for your diagnosis. It may confirm or change the diagnosis, point to a different stage, or type of cancer, or provide a different treatment plan for you. You will be sure that you have explored all the options in each case.


This is true especially if you have been diagnosed with a rare type of cancer. Consulting a second specialist means minimizing the chance of misdiagnosis and therefore getting the right treatment for your disease and stage.


Our knowledge about cancer and how to treat it is at a rapid change.  Every year, new studies about what can be the most effective treatment are published. Although most doctors keep their knowledge up to date, sometimes it is impossible to keep up with all the new information.


Getting a multidisciplinary approach raises the chances of successful treatment. Consulting an oncologist, a surgeon and a radiation oncologist might give you a wider specter of the opportunities that you might have to do best.


If you felt fear or doubt after receiving your initial diagnosis, maybe consulting a second doctor will give you hope. Sometimes, our intuition can be stronger than any knowledge.


A second opinion means more information about your diagnosis. Making an informed decision will make you feel more in control of your disease and raise the chances that you succeed in the end.

Radiotherapy Radiotherapy

Radiation Treatment and Radiosurgery

What is Radiation Treatment?

Radiation has been an effective tool for treating cancer for more than 100 years. Radiation oncologists are doctors trained to use radiation therapy to treat cancer. Radiation therapy is in fact one of the fundamental treatment modalities for cancer. About two-thirds of all cancer patients will receive radiation therapy as part of their treatment at some point during their disease.

What is Radiosurgery?

Radiosurgery is a different type of radiation therapy and it differs from classical radiation therapy in several respects. In radiosurgery, the surgeon uses radiation energy to create an effect at a very precise location in the brain just like using electric energy to cut through tissue or close blood vessels. The procedure is completed in a single session and the surrounding brain tissue receives a negligible amount of radiation, unlike the standard external beam radiation therapy techniques where the surrounding brain tissue is subjected to a considerable dose of radiation given in small increments over several weeks to allow normal brain tissue to recover from its effect, while tumor tissue is unlikely to recover. Ultimately, the brain will absorb a maximal dose of radiation, beyond which no further treatment can be performed. There is a shred of increasing evidence that, over long periods of time, high doses of radiation are harmful to the normal functioning brain.

What is Gamma Knife?

Gamma knife has been the first radiosurgery technique to treat tumors and other abnormalities in the brain. In Gamma Knife radiosurgery, the target tissue receives a very high dose of radiation in a single session, while the adjacent brain tissue is exposed only to a negligible dose of radiation.

Gamma knife first became commercially available in 1968. In the beginning, it was offered in very few centers around the world. As its therapeutic benefits were confirmed in time, its sphere of use widened. Today, Gamma Knife is being used in about 300 centers around the world. Over a million patients with a variety of brain diseases had been treated with Gamma Knife. There are no other devices in this field that can deliver the precision of Gamma Knife and that has helped this many people.

Which diseases can be treated with Gamma Knife?

  • Patients with benign brain tumors: Vestibular schwannomas (tumors which arise from the nerve sheath of the hearing-balance nerve); meningiomas (which arise from the coverings of the brain), pituitary adenomas (tumors of the hormone-secreting pituitary gland), other skull base tumors or other specific brain tumors (craniopharyngiomas, hemangioblastomas, tumors of the pineal region)
  • Patients with blood vessel anomalies: Arteriovenous malformations, cerebral cavernous malformations of cavernomas, and dural arteriovenous fistulas.
  • Patients with malignant tumors: First and foremost of these are metastatic tumors in the brain (which arise from systemic cancers such as lung, breast, colon, or malignant melanoma), uveal melanoma, certain glial tumors, hemangiopericytoma, nasopharyngeal carcinomas.
  • Patients unable to tolerate surgical procedures for reasons such as age or associated medical conditions: Gamma Knife treatment is administered without the need to go to the operating room or without the need to receive general anesthesia in adults.
  • Patients with functional diseases: Such as trigeminal neuralgia, which is a chronic pain disorder that affects the face.
  • Patients with movement disorder: Tremor associated with Parkinson’s disease.
  • Patients who refuse open surgery.

The advantages of Gamma Knife Treatment of Brain tumors:

  • It is very effective
  • The risk of adverse events after the procedure is very low
  • It can eliminate the need for open surgery for many types of brain tumors
  • It does not require general anesthesia
  • It does not require going to the operating room
  • There are no incisions on the scalp or head
  • The patient feels very little discomfort
  • Normal brain tissue is exposed to very little radiation
  • Hair does not have to be cut and does not fall out
  • Patients return to their homes or work on the day of treatment
  • There is no recovery period
  • It is less expensive than most surgical procedures

The Gamma Knife Process

Treatment is planned according to the specific needs of individual patients and this customized process is very easy, fast, reliable, safe, ad straightforward.

The computer software of Gamma Knife reduces the treatment plan to a list of simple instructions to guide the gamma rays to target.

The treatment begins by fitting the stereotactic frame to the patient’s head. This is easily done within minutes and requires only local anesthesia. Once the frame has been fitted, an imaging procedure suitable for the patient’s pathology (i.e. MRI, CT, angiography) is performed. These studies create a very detailed and precise using a special computerized planning program. The treatment is fitted to cover the target with an accuracy of less than a millimeter while protecting the surrounding brain and nerve tissue with exquisite safety. Then the treatment is administered usually for 30 minutes to one and a half hours. Only for a few medical conditions, it can last longer. While the treatment is administered, the patient peacefully rests on the treatment couch and listens to music. Following treatment, the frame is removed and most patients are discharged from the hospital on the same day. There is no need to return to the hospital again after Gamma Knife procedures, unlike most other surgical procedures. The patients continue with their routine life the way they did one day before the procedure.


Radiotherapy: Side effects

Side effects are all the problems that come as a result of the treatment.

In radiotherapy, because of the high dose radiation that is used to kill the cancer cells, the normal, healthy cells can also be effected.

It is very important to talk to your doctor before the treatment about the possible side effects and how to minimize them. Most of the possible side effects will be gone within 2 months after the end of treatment.

One of the most important factors for the different side effects is the area of the body that is being treated (Table 1)

 DiarrheaFatigueHair lossOral cavity changesNauseaSexual dysfunctions and infertilityUrinary problemsSkin ChangesOthers
Brain    Headache Blurred vision
Breast     Sensitivity
Chest     Cough
Head    Changes in taste
Stomach and abdomen   
Table 1


The following infographics give a piece of summarized information about the most common post-radiotherapy side effects and what can you do to control them. 

Remember to always consult your doctor or nurse about all the concerns that you might have.

Medical Oncology


Lung cancer develops from the bronchial mucosa cells, but it can also develop from every other cell in the respiratory system- alveoli, bronchioles, or trachea. 
There are several types of lung cancer, while the most common are: Small cell and non-small-cell lung cancer. It is very important to differentiate these two kinds of cancer since the prognosis and the treatment of the two are very different.

Non-small-cell lung carcinoma (NSCLC) – accounts for around 85% of lung cancer cases. The most common types of NSCLC are:

  • squamous-cell carcinoma
  • large-cell carcinoma
  • adenocarcinoma
  • Some other rare forms.

Small-cell lung carcinoma is found in around 10-15% of the patients diagnosed with lung cancer. This type of cancer is very aggressive.

Lung cancer is the leading cause of cancer death worldwide. Modern medicine aims to explore various methods to achieve control over the disease.


It is proved that some factors play a negative role in the development of lung cancer. Some of these factors are:

  • Smoking
  • Passive smoking
  • Radon gas exposure 
  • Asbestos exposure 
  • Family history for lung cancer
  • Emphysema and other inflammatory-destructive lung diseases.


  • Coughing that gets worse or doesn’t go away.
  • A change in smoker’s cough.
  • Coughing up blood 
  • Shortness of breath
  • Infections such as bronchitis and pneumonia that don’t go away or keep coming back
  • Hoarseness
  • Shoulder pain
  • Bone pain, Headache, pathological fractures- due to metastasis
  • Paraneoplastic syndromes


Imaging diagnostic is the first step for the diagnosis of lung cancer. CT or PET-CT gives a more detailed image of the process in the lungs. 
Depending on the localization of the process, the next step is getting a biopsy from the process. It can be obtained by fibro bronchoscopy. Knowing the histology of the process can help your doctor to plan a more individual and effective treatment plan.

Diagnostic procedures

  • Clinical examination 
  • Sputum examination- macroscopic and microscopic
  • Blood examination- hematological, biochemical, tumor markers. 
  • Chest X-ray
  • CT
  • MRI
  • Bronchoscopy and biopsy
  • Transthoracic biopsy.
  • Bronchial lavage 
  • Mediastinoscopy with lymph nodes biopsy 
  • PET-CT
  • Bone CT scan
  • Spirometry 
  • Ki-67 assessment 
  • Grading 
  • PD-L1 assessment 
  • Genetic profiling for adenocarcinoma.


The staging of lung cancer is characterized by complex indicators that define the grade of its development. The most used staging system is the TNM system.

  • T (T1 to T4) stands for the size and the level of invading of the cancer cells.
  • N (N0 to N3) is the index for lymph nodes involvement. 
  • M0 or M1 indicates if there is metastasis or not.


The standard treatment of lung cancer includes three methods: Surgery, radiotherapy, and chemotherapy or immunotherapy. Surgery is a very good option in local NSCLC. For all the other types and stages, the combination of the three methods caries better chances of success.

Nevertheless, depending on the stage or the type of cancer, the decision for the right treatment is quite complex.

For the metastatic stage, the goal of the treatment is to reach control of the disease, prevention of the symptoms, good quality of life, and potentially prolongation of survival.


Definitive radio-chemotherapy is the standard treatment for many patients with locally advanced non-small-cell lung cancer (NSCLC). 
Radiosurgery is used to treat tumors in the lung without having to make an opening in the skin (incision). This procedure is generally used for people who cannot have surgery because of age, lung disease, or heart disease. Its role is very important especially for SCLC with brain metastasis.


Patients with advanced non-small-cell lung cancer (NSCLC) are currently treated with chemotherapy, targeted therapies, and immune checkpoint inhibitors. 
Chemotherapy is the primary treatment for SCLC. Additional treatment depends on whether or not it is limited-stage SCLC or extensive-stage SCLC.

For limited-stage SCLC, chemotherapy is
often combined with radiation therapy to the chest.

For extensive-stage SCLC, chemotherapy is
often combined with immunotherapy.



Radiotherapy uses high-energy ionizing radiation to kill cancer cells.

The ionizing radiation can be used from the outside of the body (external beam radiation) or can be implanted in the zone where the cancer cells are (brachytherapy).

The success of radiotherapy is measured by how personalized it is and how much it preserves the healthy cells while radically killing the cancerous ones.


In this form of radiotherapy, a temporary implant with a radioactive isotope is implanted in the prostate gland and this allows that a high dose of ionizing radiation is concentrated in the tumor.
The surrounding tissues are less affected compared to the external beam radiation. The procedure of implanting the isotope lasts less than one hour and can be done ambulatory. 1 to 5 procedures are needed for a full course. 
Brachytherapy is appropriate for patients with low to medium risk prostate cancer and in selected patients with high-risk cancer.
In some patients, problems with urination or a need for catheterization can be seen as an adverse effect.


This is the most common form of radiotherapy. Before the treatment, the doctor uses the CT that is done before the procedure to mark the exact place where the beams will the concentrated. The procedure lasts a few minutes and normally should be done 5 times a week for several weeks. 
3D-CRT, IMRT/VMAT IMRT/IGRT are some of the technical varieties that can be used for external beam radiation.


At the beginning of the course of radiotherapy for prostate cancer, the patient might feel tired, have nausea, and lack appetite. Because of this, it is important that the patient rests when the course is started. 
The adverse effects of the therapy start in the middle of the course and might continue up to 1 month after the end of the therapy. The most common adverse effects are:

  • Nausea and vomiting
  • Diarrhea 
  • Inflammation of the hemorrhoids
  • Frequent urination
  • Lack of appetite
  • Loss of hair in the zone of radiation


  • Rectal bleeding
  • Strictures of the urethra 
  • Erectile dysfunction
  • Change in the frequency of urination


  • Cease smoking and drinking alcohol 
  • Drink more liquids
  • Keep good hygiene 
  • Keep the radiated zone away from the sun

Medical Oncology


Prostate cancer is a malignant tumor that is developed in the prostate gland in men. It is the second most common cancer in men, after skin cancer.

It is estimated that 1 in 8 men will be diagnosed with prostate cancer during their lifetime. 65% of the cases are diagnosed in men over the age of 65. Many of the men with prostate cancer have the so-called clinically insignificant form of cancer. This means that the cancer is strictly developed in the gland and does not become invasive. This way, the patient might live for years with cancer without any indication for the problem.

The most common histological type of prostate cancer is adenocarcinoma. It is developed by the cells that produce the liquid that is the main part of the sperm. The more the cancer cells look like the original normal cells, the more high-differentiated the cancer is, and the better the prognosis. If the cancer cells do not look like normal cells then cancer is low differentiated or anaplastic.


The diagnosis of prostate cancer involves:

  • A physical examination by a urologist
  • Trans rectal echography 
  • Prostate biopsy 
  • PSA level 
  • CT, MRI, SPECT/CT, or PET/CT with 68Ga PSM for staging.

PSA is a protein that is produced by the prostate gland. From the late ‘80s, the level of PSA is used as a screening method for prostate cancer. High PSA levels can be a predictor for prostate cancer or another benign condition like benign prostatic hyperplasia. Another indicator of cancer activity is the Gleason score that is determined by the pathologists from the biopsy of the gland.

Another indicator of cancer activity is the Gleason score that is determined by the pathologists from the biopsy of the gland.

TNM classification (T-tumor; N-nodules; M-metastasis) is the most commonly used classification for staging prostate cancer. T-tumor describes the status of the primary tumor. It can vary from T0 that means no palpable tumor to T4 which means t the tumor has invaded the neighboring organs. N0 and N1 mean no metastasis in the regional lymph nodes or the presence of such respectively. M0 and M1 mean the lack and the presence of metastasis in distant organs.

The individual treatment plan is composed based on the PSA, GLEASON, and TNM.

Before treatment, the patient must have a complex grade with MRI, SPECT/CT, or PET/CT with 68Ga PSMA. The latter has been recently FDA approved and gives a higher rate of precision when it comes to staging of distant prostate cancer.


ACTIVE SURVEILLANCE:  Low-grade prostate cancer may not need treatment right away. For some, treatment may never be needed. Instead, doctors sometimes recommend active surveillance. In active surveillance, regular follow-up blood tests, rectal exams, and prostate biopsies may be performed to monitor the progression of your cancer. If tests show your cancer is progressing, you may opt for a prostate cancer treatment such as surgery or radiation.

SURGERY: Radical removal of the prostate gland is an option for treating cancer that is confined to the prostate. It is sometimes used to treat advanced prostate cancer in combination with other treatments.

RADIATION: Radiation therapy uses high-powered energy to kill cancer cells. For all the options of radiotherapy to treat prostate cancer, check out our blog (

HORMONAL THERAPY: Drugs that lower the production of testosterone are used for the treatment of prostate cancer that is spread outside the gland.

IMMUNOTHERAPY: In case the cancer is resistant to conventional drugs of hormonal therapy, immunotherapy with so-called check-point inhibitors or PARP-inhibitors can be used

CHEMOTHERAPY: Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form, or both. Chemotherapy may be a treatment option for treating prostate cancer that has spread to other areas of the body. Chemotherapy may also be an option for cancers that don’t respond to hormone therapy.

Medical Oncology

Testicular cancer: an overview

Testicular cancer is a disease where cancer cells develop in the testicular tissues. More commonly it develops only in one of the testis, but in some rare cases, it can be found bilaterally. Caucasian men between the ages of 20 to 45 are the risky population to develop testicular cancer


The most common symptom of testicular cancer is a swollen, sometimes painful upon touching, lump. Upon finding such a lump, it is urgent to visit a doctor. The doctor will perform a physical examination and an Ultrasound of the testis. He might also require to test the level of some tumor markers in your blood. The tumor markers that can be indicative of testicular cancer are Alpha-Fetoprotein (AFP), Human chorionic gonadotropin (hCG or beta- hCG), and lactate dehydrogenase (LDH). Finally, a CT of the thorax, abdomen, and the pelvis can be performed to stage the disease. 

Types of testicular cancer

More than 90% of the testicular testis develop from the germ cells (the cells that make sperm). The main types of germ cell tumors (GCTs) in the testicles are seminomas and non-seminomas.

  • Seminomas grow slowly and are usually located only in the testis.
  • Non-seminomas grow more rapidly and can quickly disseminate in the entire body. 

Seminomas are more radiosensitive, while both seminomas and non-seminomas respond to chemotherapy. 

More than 90% of the testicular testis develop from the germ cells (the cells that make sperm). The main types of germ cell tumors (GCTs) in the testicles are seminomas and non-seminomas.

Seminomas grow slowly and are usually located only in the testis.

Non-seminomas grow more rapidly and can quickly disseminate in the entire body. 


 The treatment of testicular cancer depends on the stage of cancer.

Stage 0- In these cases, there is some development of cancer cells but these cells do not grow outside the tubules where sperm are formed. This stage is called Intratubular germ cell neoplasia (ITGCN). Sometimes, low dosage radiotherapy can be used for the treatment of testicular cancer in this stage. 

Stage 1-The cancer has invaded tissues next to the testicle but has not spread to lymph nodes or more distant sites in the body. Levels of tumor marker proteins may be normal or elevated. In all cases, surgical removal of the testicle. The three subcategories of stage 1 testicular cancer are:

  • Stage 1A: The tumor may have grown through the inner layer of tissue surrounding the testicle, but not the outer layer, and it has not spread to blood or lymph vessels. Serum levels of tumor markers are normal. A short chemotherapy course can be used for treatment.
  • Stage 1B: Tumors at this stage may have spread to blood or lymph vessels or may have invaded the outer layer surrounding the testicle, the spermatic cord, or the scrotum. Serum levels of tumor markers are normal. . A short chemotherapy course can be used for treatment.
  • Stage 1S: These cancers can demonstrate any degree of invasion of nearby tissues, and levels of tumor markers measured after the tumor has been removed by surgery are elevated. A full course of chemotherapy is obligatory. 

Stage 2- Testicular cancers at this stage have invaded tissues next to the testicle and can now be found in at least one nearby lymph node. Tumor marker levels may be normal or slightly elevated. Stage 2 testicular cancer has three subcategories:

  • Stage 2A: Tumors at this stage have spread to one or more lymph nodes, but no node is larger than 2 cm.
  • Stage 2B: Tumors at this stage have spread to at least one lymph node, which is between 2 cm and 5 cm in size.
  • Stage 2C: These tumors have spread to at least one lymph node that is larger than 5 cm.

The treatment, in this case, depends on the type of cancer. 

In cases of small sizes seminomas- surgical removal plus radiotherapy. For large size seminomas (more than 5cm)- surgical removal plus chemotherapy. 

For small size non-seminomas (less than 2-3cm)- Surgical removal of the testis and some of the lymph nodes and then, eventually, chemotherapy. For large size non-seminomas- Surgical removal of the testis, chemotherapy, and later surgical lymph nodes removal. 

Stage 3 testicular cancer: Testicular cancers at this stage have spread to distant lymph nodes or organs. Stage 3 testicular cancer has three subcategories:

  • Stage 3A: These cancers have spread to a distant lymph node or the lungs. Tumor marker protein levels are normal or slightly elevated.
  • Stage 3B: At this stage of testicular cancer, patients have moderately elevated levels of tumor marker proteins, and the disease has either spread to nearby or distant lymph nodes, or the lungs.
  • Stage 3C: These cancers have high levels of tumor marker proteins and may have spread to nearby or distant lymph nodes, or the lungs. Alternatively, they may have spread to other distant organs, such as the liver or the brain, but in this case, serum tumor markers can be at any level.

The treatment in this stage is surgical testicular removal and multidrug chemotherapy. In non-seminomas, surgical lymph nodes removal might be necessary after the chemotherapy.

Due to the risk of recurrence, it is important to schedule regular exams to ensure the cancer hasn’t returned. Follow-up exams are likely to be most frequent in the first two years after treatment concludes. 

Medical Oncology

Diagnosis of Breast Cancer


The good news is that mortality from breast cancer has declined by 2 % each year since 1990, and this is because of the increased awareness, screening and, better methods of early diagnosis and treatment. For early diagnosed patients, the five year survival rate is above 95%.


Like all the diagnoses, the first step is history taking. Your doctor will ask about your personal and your family health history. Next, he may require one or more than one of the following tests:

Physical exam: During the exam, the doctor will inspect and palpate the breast and exam the lymph nodes in the underarm area. A specialist can differentiate a benign from a malignant lump by physical exam alone.  

Digital Mammography: This X-ray of the breast gives further information about the nature of a detected lump. This test can detect even lumps that are too small to be detected by palpation. Digital mammography uses computer-based electronic conductors for a clearer image, even for women with denser breast tissue.

MRI: This test can detect cancer not visible on conventional imaging. It is recommended to be done yearly in patients with a high risk of breast cancer.

Ultrasound: This test uses sound waves to characterize the lump on the breast – whether it is a cyst or a solid mass (benign or malignant).

Based on the results from these tests, the doctor may require a biopsy of the breast tissue. This biopsy can be taken surgically (excisional biopsy) or by a needle under ultrasound control. After this, the biopsied tissue is sent for histological confirmation. The pathologist will describe if there is a malignant tumor and if so, what type it is. This is a crucial step of the diagnosis and necessary to form the best treatment plan.