ASTRO 2022: Interesting presentations

[Palex80]

Hey! I am reading on some interesting presentations at ASTRO this year, mostly from Twitter.

I thought I'd make a thread to discuss on those.

Here's the first one:


Interesting findings, although not practice changing, in my humble opinion.
It will however make me feel more comfortable irradiating asymptomatic bone mets with more than just a gut feeling to back it up.

It will be interesting to see the breakdown of the SREs in the control arm, i.e. is there a true benefit for the patients or are we merely introducing RT earlier on but not changing any other endpoints (fractures, hospitalizations, surgeries).

I would not overemphasize the overall survival benefit. KPS was also significant in the MVA and there was an imbalance in the trial with the intervention arm having more patients in excellent KPS than the control arm, something which is not uncommon in Phase II trials.



The protocol of the trial has been published before, for those of you that may have protocol-relevant questions:

Early palliative radiation versus observation for high-risk asymptomatic or minimally symptomatic bone metastases: study protocol for a randomized controlled trial - BMC Cancer

Background In patients with metastatic cancer, the bone is the third-most common site of involvement. Radiation to painful bone metastases results in high rates of pain control and is an integral part of bone metastases management. Up to one-third of inpatient consults are requested for painful...

bmccancer.biomedcentral.com

Interesting point: They randomized 93 patients, although they had "planned" to randomize only 74 per protocol. The incidence of SREs in the trial appears to have been lower that what they had thought?

DISCUSS!

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[TheWallnerus]

My main question is

Will Evicore believe the results of this trial?

 

[Ray D. Ayshun]

RTOG 1005 sounds like something I'd like in the long run

Purpose/Objective(s):

Randomized trials support a supplemental radiation dose (Boost) to the lumpectomy (L) cavity region after whole breast irradiation (WBI), providing a 20-30% relative reduction of in-breast recurrence (IBR); with the disadvantage that it extends treatment duration ⁓ 1 week. Hypofractionated WBI (H-WBI) in ≤ 3 weeks is used after L to deliver adjuvant WBI with acceptable toxicity and comparable IBR as conventional WBI (C-WBI) 50 Gy in 2 Gy fractions (F). NRG RTOG 1005 sought to determine whether a boost delivered concomitantly with H-WBI over 15 F is non-inferior for IBR compared to boost delivered sequentially after C-WBI in patients (pts) considered at High Risk of IBR.


Materials/Methods:

Protocol-specified High Risk pts post L with stages 0, I & II breast cancer were randomized to C-WBI 50 Gy in 25 F or 42.7 Gy in 16 F plus sequential boost of 12 Gy in 6 F or 14 Gy in 7 F (Arm I) or H-WBI 40 Gy in 15 F plus concomitant boost of 8 Gy in 15 F of 0.53 Gy per day (Arm II). Radiation was target based 3-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT) and quality review (QA) was required. Stratification was by age (<50 vs ≥ 50), adjuvant chemotherapy (Y vs N), ER status (+ vs -) and histologic grade (1, 2 v 3). The primary endpoint is IBR. Assuming Arm I 5‐year IBR of 1.59%, 90% CI upper bound hazard ratio (HR) of 2.12 and 1‐sided significance level = 0.05, 2150 pts with at least 46 IBR events provide >80% power to conclude non‐inferiority. IBR was analyzed comparing the cause-specific hazards. Adverse Events (AE) were graded with NCI CTCAE v4. Physician-reported NRG-RTOG Global Cosmetic Score (GCS) was grouped as excellent/good vs fair/poor, and arms compared with chi-square.


Results:

2262 of 2354 randomized pts were eligible (Arm I n=1124; Arm II n=1138). Median age 55 years, 34% Stage II, 52% grade 3, 30% ER-, 17% close/+ margins consistent with a “High Risk” population. Radiation was 3DCRT 81%, IMRT 19%, and the QA was per protocol 81% and 88% on Arm I vs II, respectively. With a median follow-up of 7.3 years and 56 IBR events, the 5 and 7-year IBR were 2.0% and 2.2% on Arm I and 1.9% and 2.6% on Arm II. The non-inferiority comparison (Arm I reference level) resulted in a HR (90% CI): 1.32 (0.84, 2.05) and p = 0.039, thus meeting non-inferiority. No differences in AEs noted between arms, with low rates of ≥ grade 3 treatment-related AEs, 3.3% vs 3.5% for Arm I vs II, respectively (p=0.79). No difference in 3-year excellent/good cosmesis by arm: 86% for Arm I vs 84% Arm II (p=0.61).


Conclusion:

Concomitant boost with H-WBI results in non-inferior IBR compared to sequential boost after C-WBI in High Risk cases and reduces overall treatment time. Using target based 3DCRT or IMRT, there are no differences in toxicity or cosmetic outcome for concomitant v sequential boost or the WBI fractionation regimen.

Interesting how little presumably true IMRT (not ecomp etc) was used in this trial. I suspect it was used more in Arm II, which explains higher QA per protocol rate. If arm II got exclusively true IMRT, I suspect it would've been close to 100%. Would we then have seen less toxicity in the sib arm?

 

[TheWallnerus]

RTOG 1005 sounds like something I'd like in the long run

Purpose/Objective(s):

Randomized trials support a supplemental radiation dose (Boost) to the lumpectomy (L) cavity region after whole breast irradiation (WBI), providing a 20-30% relative reduction of in-breast recurrence (IBR); with the disadvantage that it extends treatment duration ⁓ 1 week. Hypofractionated WBI (H-WBI) in ≤ 3 weeks is used after L to deliver adjuvant WBI with acceptable toxicity and comparable IBR as conventional WBI (C-WBI) 50 Gy in 2 Gy fractions (F). NRG RTOG 1005 sought to determine whether a boost delivered concomitantly with H-WBI over 15 F is non-inferior for IBR compared to boost delivered sequentially after C-WBI in patients (pts) considered at High Risk of IBR.


Materials/Methods:

Protocol-specified High Risk pts post L with stages 0, I & II breast cancer were randomized to C-WBI 50 Gy in 25 F or 42.7 Gy in 16 F plus sequential boost of 12 Gy in 6 F or 14 Gy in 7 F (Arm I) or H-WBI 40 Gy in 15 F plus concomitant boost of 8 Gy in 15 F of 0.53 Gy per day (Arm II). Radiation was target based 3-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT) and quality review (QA) was required. Stratification was by age (<50 vs ≥ 50), adjuvant chemotherapy (Y vs N), ER status (+ vs -) and histologic grade (1, 2 v 3). The primary endpoint is IBR. Assuming Arm I 5‐year IBR of 1.59%, 90% CI upper bound hazard ratio (HR) of 2.12 and 1‐sided significance level = 0.05, 2150 pts with at least 46 IBR events provide >80% power to conclude non‐inferiority. IBR was analyzed comparing the cause-specific hazards. Adverse Events (AE) were graded with NCI CTCAE v4. Physician-reported NRG-RTOG Global Cosmetic Score (GCS) was grouped as excellent/good vs fair/poor, and arms compared with chi-square.


Results:

2262 of 2354 randomized pts were eligible (Arm I n=1124; Arm II n=1138). Median age 55 years, 34% Stage II, 52% grade 3, 30% ER-, 17% close/+ margins consistent with a “High Risk” population. Radiation was 3DCRT 81%, IMRT 19%, and the QA was per protocol 81% and 88% on Arm I vs II, respectively. With a median follow-up of 7.3 years and 56 IBR events, the 5 and 7-year IBR were 2.0% and 2.2% on Arm I and 1.9% and 2.6% on Arm II. The non-inferiority comparison (Arm I reference level) resulted in a HR (90% CI): 1.32 (0.84, 2.05) and p = 0.039, thus meeting non-inferiority. No differences in AEs noted between arms, with low rates of ≥ grade 3 treatment-related AEs, 3.3% vs 3.5% for Arm I vs II, respectively (p=0.79). No difference in 3-year excellent/good cosmesis by arm: 86% for Arm I vs 84% Arm II (p=0.61).


Conclusion:

Concomitant boost with H-WBI results in non-inferior IBR compared to sequential boost after C-WBI in High Risk cases and reduces overall treatment time. Using target based 3DCRT or IMRT, there are no differences in toxicity or cosmetic outcome for concomitant v sequential boost or the WBI fractionation regimen.

Interesting how little presumably true IMRT (not ecomp etc) was used in this trial. I suspect it was used more in Arm II, which explains higher QA per protocol rate. If arm II got exclusively true IMRT, I suspect it would've been close to 100%. Would we then have seen less toxicity in the sib arm?

This trial proves #radonc is still irrational about breast IMRT.

 

[theradiator]

Hey! I am reading on some interesting presentations at ASTRO this year, mostly from Twitter.

I thought I'd make a thread to discuss on those.

Here's the first one:


Interesting findings, although not practice changing, in my humble opinion.
It will however make me feel more comfortable irradiating asymptomatic bone mets with more than just a gut feeling to back it up.

It will be interesting to see the breakdown of the SREs in the control arm, i.e. is there a true benefit for the patients or are we merely introducing RT earlier on but not changing any other endpoints (fractures, hospitalizations, surgeries).

I would not overemphasize the overall survival benefit. KPS was also significant in the MVA and there was an imbalance in the trial with the intervention arm having more patients in excellent KPS than the control arm, something which is not uncommon in Phase II trials.



The protocol of the trial has been published before, for those of you that may have protocol-relevant questions:

Early palliative radiation versus observation for high-risk asymptomatic or minimally symptomatic bone metastases: study protocol for a randomized controlled trial - BMC Cancer

Background In patients with metastatic cancer, the bone is the third-most common site of involvement. Radiation to painful bone metastases results in high rates of pain control and is an integral part of bone metastases management. Up to one-third of inpatient consults are requested for painful...

bmccancer.biomedcentral.com

Interesting point: They randomized 93 patients, although they had "planned" to randomize only 74 per protocol. The incidence of SREs in the trial appears to have been lower that what they had thought?

DISCUSS!

At least someone is doing a study that seeks to expand radiation oncology practice!

 

[Palex80]

My main question is

Will Evicore believe the results of this trial?

Every patient has pain from the bone met. You just need to apply adequate pressure during the physical exam.

 

[TheWallnerus]

Every patient has pain from the bone met. You just need to apply adequate pressure during the physical exam.

Haha. I think one of take homes from this trial though is also to SBRT the mets? Evicore hates bone met SBRT with a passion.

 

[Palex80]

Haha. I think one of take homes from this trial though is also to SBRT the mets? Evicore hates bone met SBRT with a passion.

30% was SBRT, the rest not.

 

[BobbyHeenan]

Haha. I think one of take homes from this trial though is also to SBRT the mets? Evicore hates bone met SBRT with a passion.

yes, evicore will be glad to approve a 2D/complex isodose for these patients.
Good luck getting SBRT approved in spite of MD Anderson trial or the canadian randomized trial. Sometimes with a fight you'll get it...but it shouldn't be that tough.

 

[grenz]

https://www.astro.org/ASTRO/media/ASTRO/Meetings%20and%20Education/PDFs/AM22/AM22_LBAs.pdf

Those are the late breaking abstracts. I am struck by how many of these trials expand the indications for radiation. Not a single hypofrac/de-escalation trial. Not great results for immunoRT combinations, however.

 

[communitydoc13]

https://www.astro.org/ASTRO/media/ASTRO/Meetings%20and%20Education/PDFs/AM22/AM22_LBAs.pdf

Those are the late breaking abstracts. I am struck by how many of these trials expand the indications for radiation. Not a single hypofrac/de-escalation trial. Not great results for immunoRT combinations, however.

MSKCC doing good work in the metastatic setting.

 

[BobbyHeenan]

MSKCC doing good work in the metastatic setting.

I think it's great work. LIke someone else said, if that were a drug with those phase II results we'd see headlines everywhere. Just last week I had multiple inpatient consults for pain related skeletal events/admissions. Surely some of that is preventable.

someone ?scarbrtj? had posted their SBRT for mets volume and it is a crazy amount of patients. I don't think it's "wrong," but definitely more than I would expect or I see and do in my clinic. Have no clue how they get that by insurance because I'm sometimes not successful for that.

 

[thesauce]

At least someone is doing a study that seeks to expand radiation oncology practice!

Agreed, but aren’t many already doing this is certain situations such as proximal femur met to prevent fracture?

 

[theradiator]

MSKCC doing good work in the metastatic setting.

Interesting sociology regarding why metastatic disease was underexplored in the past.

The old timers will remember that metastatic disease was the dumping ground for junior faculty and was not helpful for promotion because of a 'need to own a disease site'. Until recently, metastatic disease was not one of those acceptable sites. MSK created a metastatic disease site subdivision that helped overcome this limitation and now metastatic disease and palliation can be its own subspecialty. We are now seeing the fruits of that decision, which was progressive at the time. While I have been critical of MSK when warranted, hats off to them for rigorously studying when RT is useful and effective for metastatic disease.

 

[Gfunk6]

Hey! I am reading on some interesting presentations at ASTRO this year, mostly from Twitter.

I thought I'd make a thread to discuss on those.

Here's the first one:


Interesting findings, although not practice changing, in my humble opinion.
It will however make me feel more comfortable irradiating asymptomatic bone mets with more than just a gut feeling to back it up.

It will be interesting to see the breakdown of the SREs in the control arm, i.e. is there a true benefit for the patients or are we merely introducing RT earlier on but not changing any other endpoints (fractures, hospitalizations, surgeries).

I would not overemphasize the overall survival benefit. KPS was also significant in the MVA and there was an imbalance in the trial with the intervention arm having more patients in excellent KPS than the control arm, something which is not uncommon in Phase II trials.



The protocol of the trial has been published before, for those of you that may have protocol-relevant questions:

Early palliative radiation versus observation for high-risk asymptomatic or minimally symptomatic bone metastases: study protocol for a randomized controlled trial - BMC Cancer

Background In patients with metastatic cancer, the bone is the third-most common site of involvement. Radiation to painful bone metastases results in high rates of pain control and is an integral part of bone metastases management. Up to one-third of inpatient consults are requested for painful...

bmccancer.biomedcentral.com

Interesting point: They randomized 93 patients, although they had "planned" to randomize only 74 per protocol. The incidence of SREs in the trial appears to have been lower that what they had thought?

DISCUSS!

Thanks for posting Palex - really nice trial. Never thought I'd see an RCT re: bone mets that resulted in an OS increase. I'm really glad to see that some Rad Oncs are able to pump out quality data that enhances our field rather than diminishing it.

 

[radiation]

Thanks for posting Palex - really nice trial. Never thought I'd see an RCT re: bone mets that resulted in an OS increase. I'm really glad to see that some Rad Oncs are able to pump out quality data that enhances our field rather than diminishing it.

https://www.nejm.org/doi/full/10.1056/nejmoa1213755

would be interesting to see which skeletal events correlates most to overall survival but signal has been shown in other situations

 

[Palex80]

So, if 2/3 of the SREs were "pain", then let me be devil's advocate:

a) Is this trial positive but the interpretation (driven by 2/3 of the events) is "If you don't irradiate an asymptomatic bone met upon diagnosis, it's more likely you will have to irradiate it later on due to pain"? Did we really need a trial to tell us that?
b) I would really like to see when these "pain-SREs" occured. If many of these "pain-SREs" occured pretty soon after the randomization, we may be dealing with patients and caregivers being biased (knowing that they are in the control arm) and then starting to feel / score pain in up until then asymptomatic lesions. I can imagine some patients being "disappointed" they ended up in the control arm and do not get the "intervention", but they may also know how they can get it, depending on how the patient consent form was written out.

Just some food for thought...

 

[RadOncBeamer]

To go along with your devil’s advocate, even if 2/3 SREs are pain related, Isn’t it worthwhile to consider prophylactic treatment to prevent these patients from having pain in the first place? There are so many factors that negatively impact QoL in metastatic patients, I would think that giving 8 Gy x 1 or 20/5 or SBRT to a bulky femoral head lesion to prevent future pain, fracture, or hospitalization is worthwhile, expands our indications, and is cost effective for the system. Previously, the only asymptomatic bone Mets I had been treating were oligomet patients doing SBRT to these lesions for a theoretical PFS or OS benefit (controversial…I know). This now offers an opportunity to treat a population with a higher burden of disease (think of those newly diagnosed treatment naive metastatic patients). I did not catch if there were any PRO benefits but even so, this is a low risk treatment, and as someone previously mentioned, many are already doing this…now we just have evidence

 

[NotMattSpraker]

To go along with your devil’s advocate, even if 2/3 SREs are pain related, Isn’t it worthwhile to consider prophylactic treatment to prevent these patients from having pain in the first place? There are so many factors that negatively impact QoL in metastatic patients, I would think that giving 8 Gy x 1 or 20/5 or SBRT to a bulky femoral head lesion to prevent future pain, fracture, or hospitalization is worthwhile, expands our indications, and is cost effective for the system. Previously, the only asymptomatic bone Mets I had been treating were oligomet patients doing SBRT to these lesions for a theoretical PFS or OS benefit (controversial…I know). This now offers an opportunity to treat a population with a higher burden of disease (think of those newly diagnosed treatment naive metastatic patients). I did not catch if there were any PRO benefits but even so, this is a low risk treatment, and as someone previously mentioned, many are already doing this…now we just have evidence

To add to this point (very generally), I often wish I saw patients earlier when I get palliative referrals. I hope that studies like this can facilitate that conversation.

 

[RadOncDoc21]

I send all my bone Mets to a palliative fellowship trained rad onc, thank you. So far there are only 6 rad oncs (Stanford trained) in the world who can treat a bone met effectively.

 

[medgator]

I send all my bone Mets to a palliative fellowship trained rad onc, thank you. So far there are only 6 rad oncs (Stanford trained) in the world who can treat a bone met effectively.

Doesn't Anderson have a palliative service line? Not sure if they are all fellowship trained though....

 

[RickyScott]

I have seen quite a few pts die from enlarging hilar Mets for which we were only consulted when they had obstruction/hemoptysis. Looking back at serial cts, not hard to conclude that the 6 cm asymptomatic mass on the right hilum involving pulmonary vessels will soon be a problem.

 

[ramsesthenice]

So, if 2/3 of the SREs were "pain", then let me be devil's advocate:

a) Is this trial positive but the interpretation (driven by 2/3 of the events) is "If you don't irradiate an asymptomatic bone met upon diagnosis, it's more likely you will have to irradiate it later on due to pain"? Did we really need a trial to tell us that?
b) I would really like to see when these "pain-SREs" occured. If many of these "pain-SREs" occured pretty soon after the randomization, we may be dealing with patients and caregivers being biased (knowing that they are in the control arm) and then starting to feel / score pain in up until then asymptomatic lesions. I can imagine some patients being "disappointed" they ended up in the control arm and do not get the "intervention", but they may also know how they can get it, depending on how the patient consent form was written out.

Just some food for thought...

if I could count the number of times that told someone “let me know if any other spots seem to become painful” and then hear from them in less than a few weeks. Its definitely a confounded which is almost impossible to control for. But in this case I think the whole of the data is very promising. Let’s not go doing Evicores work for them.

 

[IonsAreOurFuture]

It's been estimated that 1/4 of cancer patients die of local disease as the cause of death - airway, vascular, brain mets, liver failure, GI bleed, mass effect type complications. Brain met death was more common before radiosurgery gave us 90% local control, but we don't yet have that same power to safely control half a dozen liver mets. Ureter obstruction was more common before percutaneous neph - my palliative care mentor believed uremia to be a pretty good way to go, just fall asleep - but most people would rather be alive, even if it means having 2 tubes out your back. These are quality of life issues we can help with too - and noninvasively.

We still have a long way to go on stopping these as causes of death. These are generally not nice ways to die, and although people are justifiably concerned about controlling micro metastases for cure, there is no cure without local control.

I'm always glad to see more focus being placed on controlling what we can see and preventing what we know is coming. I just got this month's Red journal and it's dedicated to oligometastases.

 

[NotMattSpraker]

I have seen quite a few pts die from enlarging hilar Mets for which we were only consulted when they had obstruction/hemoptysis. Looking back at serial cts, not hard to conclude that the 6 cm asymptomatic mass on the right hilum involving pulmonary vessels will soon be a problem.

Yes. Throw trials requiring radiotherapy wash out in the mix and it ramps up even more. I've seen too many that had obviously decreased QoL from symptoms but didn't come to me until they were out of trial options. Then when they hear the data about effectiveness and low toxicity of short course palliative radiotherapy they get frustrated and ask why they didn't know about this option "months ago".

I'm always glad to see more focus being placed on controlling what we can see and preventing what we know is coming. I just got this month's Red journal and it's dedicated to oligometastases.

Totally agree, I hope the sum effect of all of this work is greater than each study on its own, which are easy to nit pick and describe limitations.

 

[Palex80]

Ok, so the trial was negative. Can't we just leave it there?

"Defined control arm RT+cetux in a new population"?
I thought RT + Cetux was s.o.c. for something like 15 years now in H&N cancer patients ineligible for cisplatin. Thoughts?

 

[Palex80]

A few months back we were arguing about this very thing here (hypofractionation in high-risk PCA). Thoughts?

 

[Palex80]

Could someone please elaborate on the carbon footprint of Proton-APBI?

 

[taserlaser]

Could someone please elaborate on the carbon footprint of Proton-APBI?

It takes 6 protons (and 6 neutrons) to make a carbon, so obviously 6 proton-APBIs make up a carbon-APBI. Math checks out.

 

[CaesarRO]

A few months back we were arguing about this very thing here (hypofractionation in high-risk PCA). Thoughts?

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

 

[medgator]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

 

[deleted1111261]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

This is insane .. and then the idea of immediately calling out other physicians to take up the treatment or they are a laggard?

Why do people have any respect for these folks? Create conflict where there is none.

 

[RickyScott]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

Imagine photon vs proton had increased acute gi toxicity in photon arm. Proton would be new soc.

 

[ramsesthenice]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

Son/daughter, it’s time we have a talk. This is going to be hard to hear, but you are old enough it’s time to know the truth. For a lot of people, trials are as much or more of a pathway to promotion as they are to help patients. I know, it sounds crazy. But sadly, it’s true.

The sad reality is for so long we have placed a really high reward on “positive” results and changing practice that anything less is treated like garbage or twisted into something it’s not. This is a sad example. If 50 unbiased reviewers (in medicine but not rad onc) watched that presentation what do you think their take away would be?

 

[Ray D. Ayshun]

This is insane .. and then the idea of immediately calling out other physicians to take up the treatment or they are a laggard?

Why do people have any respect for these folks? Create conflict where there is none.

I frequently go on longish day hikes. 10-15 miles. I kinda bust my ass to get through them to get home and take care of other stuff. I sometimes miss the forest and the trees. I not infrequently run into through hikers, or just slow-pokes, and blast by them, thinking, "what laggards!" I also deep down wish I were them and had the ability to better live in the moment. If I were a doc trained in the standard frac era, with a history of success treating high-risk prostate cancer and I showed up to ASTRO this year I'd think, "what laggards! Was hoping to see something promising in GBM. I already know how to treat Stage I breast and HR prostate."

 

[communitydoc13]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

We accept increased acute toxicity with decreased number of fractions as equivalent or at least "reasonable" as a field. This is often driven by cost considerations from de-facto single payor health care systems. (works to consolidate care in larger centers)

Imagine photon vs proton had increased acute gi toxicity in photon arm. Proton would be new soc.

We accept any signal at all as justification of higher cost technology (and technical reimbursement) in the US. (works to consolidate care in larger centers)

For a lot of people, trials are as much or more of a pathway to promotion as they are to help patients.

The spin on these negative trials, with self-aggrandizing descriptions of the value/innovation of the trial design included in the "conclusion" of all places, is something to behold. If it's a negative trial and it's well designed, just include the considerations of design in the discussion and reinforce that due to good design, one should be confident that the negative trial really is negative.

 

[RadRadRad]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussionYes

Imagine photon vs proton had increased acute gi toxicity in photon arm. Proton would be new soc.

Think about gyn post op Imrt vs 3D rtog trial
Imrt superior and now soc because less GI should side effects.

Now hypofrac new soc despite more GI side effects

Hard to follow this logic

 

[RadRadRad]

Think about gyn post op Imrt vs 3D rtog trial
Imrt superior and now soc because less GI should side effects.

Now hypofrac new soc despite more GI side effects

Hard to follow this logic

Also
Are we the only field in medicine that would proclaim something soc after showing it had worse side effects
Surgeons pushing hard for laparoscopic, robotic etc based on side effect profile

 

[Palex80]

Imagine photon vs proton had increased acute gi toxicity in photon arm. Proton would be new soc.

Well the issue is however price/resources.
3 Gy per fraction consume less resources and are more convenient for the patient compared to 2 Gy per fraction.
Protons will never be less resource consuming and more convenient for a patient.

I understand that the US health market does not work this way, but in (communist) Europe, we do look at these things too.

If it's only a bit more acute toxicity, which we know from the other trials may be more troublesome for some patients but usually fades away faster than during the longer schedules and at the end of the day it's the AUC that matters (are 2 weeks of grade 2 toxicity worse than 5 weeks of grade 1 toxicity?), one can say that this is one new standard of care.


Are 2 Gy/fraction wrong? No.
But 3 Gy/fraction are perfectly fine and in an enviroment with non-abundant resources, they may be the wiser choice.

 

[deleted1111261]

Well the issue is however price/resources.
3 Gy per fraction consume less resources and are more convenient for the patient compared to 2 Gy per fraction.
Protons will never be less resource consuming and more convenient for a patient.

I understand that the US health market does not work this way, but in (communist) Europe, we do look at these things too.

If it's only a bit more acute toxicity, which we know from the other trials may be more troublesome for some patients but usually fades away faster than during the longer schedules and at the end of the day it's the AUC that matters (are 2 weeks of grade 2 toxicity worse than 5 weeks of grade 1 toxicity?), one can say that this is one new standard of care.


Are 2 Gy/fraction wrong? No.
But 3 Gy/fraction are perfectly fine and in an enviroment with non-abundant resources, they may be the wiser choice.

I am a hypoFX zealot.

However, I’ve backed off on prostate. This is like breast - do the safest treatment that makes you and patient most comfortable. If 44 fx does, it’s fine. Let’s not pretend we are giving balanced counsel. I went through “options” but spent most of my time talking about 28 fx vs 5 fx with last patient. He lives 45 min away and has a job where 9 weeks will be disruptive. I told him it’s possible these will have more toxicity and it was easy decision making.

But, the judgement is too much.

 

[RickyScott]

Space oar is a standard of care because it has negligible absolute reduction in G1 toxicity.

Also, I call bs If trial has no acute increase in gu toxicity.

 

[Mandelin Rain]

Space oar is a standard of care because it has negligible absolute reduction in G1 toxicity.

THIS!

The same logic that tells you SpaceOAR is okay to foist onto (into) patients, should also tell you conventional XRT is still SOC in prostate cancer.

 

[TheWallnerus]

A few months back we were arguing about this very thing here (hypofractionation in high-risk PCA). Thoughts?

There is some really nice retrospective analysis by some group, somewhere, long time ago, that for prostate cancer late toxicity rates are strongly associated with whether patients got acute effects from the RT. I.e., to be a late effect “experiencer” the patient needs to have had some acute effects. We look at acute and late effects too disconnectedly.

Rad onc has done a wonderful job proving hypofrac is more side effect-y in prostate cancer. Part of me thinks if you have a resident and/or nurse practitioner buffer, prostate hypofrac seems more tolerable. When I get prostate cancer in old age I will insist to my 35yo rad onc to dose me at 1.8Gy per day. He will probably want to fire me as a patient.

 

[RickyScott]

There is some really nice retrospective analysis by some group, somewhere, long time ago, that for prostate cancer late toxicity rates are strongly associated with whether patients got acute effects from the RT. I.e., to be a late effect “experiencer” the patient needs to have had some acute effects. We look at acute and late effects too disconnectedly.

Rad onc has done a wonderful job proving hypofrac is more side effect-y in prostate cancer. Part of me thinks if you have a resident and/or nurse practitioner buffer, prostate hypofrac seems more tolerable. When I get prostate cancer in old age I will insist to my 35yo rad onc to dose me at 1.8Gy per day. He will probably want to fire me as a patient.

Hypofract serves interests of large centers trying to draw pts away from the community to much more expensive centers.

 

[Ray D. Ayshun]

Ok, so the trial was negative. Can't we just leave it there?

"Defined control arm RT+cetux in a new population"?
I thought RT + Cetux was s.o.c. for something like 15 years now in H&N cancer patients ineligible for cisplatin. Thoughts?

I thought altered fractionation or hypofractionation was SOC in this population. But I live in the cetuximab anaphylaxis belt.

 

[Ray D. Ayshun]

It takes 6 protons (and 6 neutrons) to make a carbon, so obviously 6 proton-APBIs make up a carbon-APBI. Math checks out.

I'm tossing around 20 Gy x 1 to the prostate in guys who drive ICE's. If I get one millenial on the jury I'm good.

 

[Palex80]

I thought altered fractionation or hypofractionation was SOC in this population. But I live in the cetuximab anaphylaxis belt.

Absolutely correct!
We always accelerate/hyperfractionate our cetuximab patients.

 

[RadOncDoc21]

I frequently go on longish day hikes. 10-15 miles. I kinda bust my ass to get through them to get home and take care of other stuff. I sometimes miss the forest and the trees. I not infrequently run into through hikers, or just slow-pokes, and blast by them, thinking, "what laggards!" I also deep down wish I were them and had the ability to better live in the moment. If I were a doc trained in the standard frac era, with a history of success treating high-risk prostate cancer and I showed up to ASTRO this year I'd think, "what laggards! Was hoping to see something promising in GBM. I already know how to treat Stage I breast and HR prostate."

I was thinking this recently with new studies coming out on how to improve things like LC, when we already have literally 95% in some disease sites.

Kinda related but why do we focus so much on dose and lowering fractions… if I can get a patient to drive an hr for 3-5 fx, why do I need to sell them with less (ie 34 Gy in lung SBRT)?

 

[NotMattSpraker]

I'm tossing around 20 Gy x 1 to the prostate in guys who drive ICE's. If I get one millenial on the jury I'm good.

Jokes aside, I was surprised to see no mention of reducing travel for treatment in these discussions.

 

[ramsesthenice]

Well the issue is however price/resources.
3 Gy per fraction consume less resources and are more convenient for the patient compared to 2 Gy per fraction.
Protons will never be less resource consuming and more convenient for a patient.

I understand that the US health market does not work this way, but in (communist) Europe, we do look at these things too.

If it's only a bit more acute toxicity, which we know from the other trials may be more troublesome for some patients but usually fades away faster than during the longer schedules and at the end of the day it's the AUC that matters (are 2 weeks of grade 2 toxicity worse than 5 weeks of grade 1 toxicity?), one can say that this is one new standard of care.


Are 2 Gy/fraction wrong? No.
But 3 Gy/fraction are perfectly fine and in an enviroment with non-abundant resources, they may be the wiser choice.

In all reality, I am with Palex on this. I think looking at this data it would be fair to say that hypofrac could be considered an acceptable SOC and in my rural state, I know for a fact a lot of patients would opt for it for convenience (side effects be damned). The problem is when payors and consensus panels get involved and start trying to decide something should be THE SOC (ie, only approving X number of fractions).

Growing up professionally in Pharma, the process of having consensus guidelines and committees haphazardly vote on topics to decide something is recommended or not is kinda mind blowing. If I made a new Covid MRN vaccine and gave this hypothetical drug a totally imperceptible and ridiculous name like say, Komernity, that required only a single shot with no boosters, worked as well as the existing options, but also had a 5% rate of non-fatal seizures the FDA would charge me in the range of $500,000-$1,000,000 to review my NDA and then tell me to eat a bowl of...