Metastases Fx Discussion

[elementaryschooleconomics]

However, prediction: it will never become SOC in US until APM

Totally agree. I like to think about this paper from 2015 on international choices of fraction # for cord compression in these discussions:

While people often make the argument that this is driven by money (and I'm sure that plays a part), I think it also has a lot to do with the culture in America. A lot of the older RadOncs I've worked with have very strong opinions about fraction sizes and safety, and they create institutional beliefs which are passed on to trainees and colleagues.

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[deleted1111261]

Totally agree. I like to think about this paper from 2015 on international choices of fraction # for cord compression in these discussions:

View attachment 346691

While people often make the argument that this is driven by money (and I'm sure that plays a part), I think it also has a lot to do with the culture in America. A lot of the older RadOncs I've worked with have very strong opinions about fraction sizes and safety, and they create institutional beliefs which are passed on to trainees and colleagues.

Okay, but if it’s not about money and the literature shows that large fraction sizes used in palliation are safe, then what is it? For example, read Candace Johnstone’s answer on TheMedNet about why people retreat more after single fraction. Has zero percent to do with efficacy or durability and anyone that says otherwise is doing it without data.

theMednet

t.co

I’m not saying people are using solely economic factors to determine fraction size for palliation. However, I have not seen one shred of evidence in favor of MFRT for bone mets. Plus, balance of data shows greater acute toxicity.

It’s not the doctor’s fault. It’s the system’s fault.

 

[TheWallnerus]

Okay, but if it’s not about money and the literature shows that large fraction sizes used in palliation are safe, then what is it? For example, read Candace Johnstone’s answer on TheMedNet about why people retreat more after single fraction. Has zero percent to do with efficacy or durability and anyone that says otherwise is doing it without data.

theMednet

t.co

I’m not saying people are using solely economic factors to determine fraction size for palliation. However, I have not seen one shred of evidence in favor of MFRT for bone mets. Plus, balance of data shows greater acute toxicity.

It’s not the doctor’s fault. It’s the system’s fault.

but I must ask, from a post I put in the other thread, would you fault anyone giving this "bone met" below 30/10? Rad oncs are theoretically in the palliation, convenience, and cancer cell killing business simultaneously

Anyone who thinks that 30/10 isn't going to have more measurable tox than 8/1 is deluded. But handwaving away the radiobiological idea that 30/10 gets more tumor response than 8/1 is also similarly deluded. That there's "not one shred of evidence in favor of MFRT for bone mets" is a little strident, no disrespect to Candace or my friend Simul. And even if in spirit true, IIRC that "not one shred of evidence" comes from a time when, versus now, metastatic patients didn't live as long. RTOG 9714 started accruing patients in the previous century. One of the arguments against 10 fraction RT for bone mets is you didn't want the shame of a patient dying within 30 days of receipt of palliative RT.

 

[deleted1111261]

but I must ask, from a post I put in the other thread, would you fault anyone giving this "bone met" below 30/10? Rad oncs are theoretically in the palliation, convenience, and cancer cell killing business simultaneously

Anyone who thinks that 30/10 isn't going to have more measurable tox than 8/1 is deluded. But handwaving away the radiobiological idea that 30/10 gets more tumor response than 8/1 is also similarly deluded. That there's "not one shred of evidence in favor of MFRT for bone mets" is a little strident, no disrespect to Candace or my friend Simul. And even if in spirit true, IIRC that "not one shred of evidence" comes from a time when, versus now, metastatic patients didn't live as long. RTOG 9714 started accruing patients in the previous century. One of the arguments against 10 fraction RT for bone mets is you didn't want the shame of a patient dying within 30 days of receipt of palliative RT.

Okay- let me re-state, because I left out a really important part.

If you’re treating for pain reduction, there is no benefit for MFRT. If you’re treating to reduce mass effect due to tumor bulk, I tend to prefer fractionation. But, in the case you’re showing - what about SBRT-esque plan with a conformal arc and give 14 Gy/1 a la MDACC study? That study showed single fraction was better for pain control, and I imagine it would provide reduction of tumor bulk, as well as 30/10 would.

And that link is only comparing MFRT to MFRT and says that dose doesn’t matter …

 

[TheWallnerus]

If you’re treating for pain reduction, there is no benefit for MFRT. If you’re treating to reduce mass effect due to tumor bulk, I tend to prefer fractionation.

ah we think exactly the same heh

 

[jondunn]

A lot of the older RadOncs I've worked with have very strong opinions about fraction sizes and safety, and they create institutional beliefs which are passed on to trainees and colleagues.

agree

 

[elementaryschooleconomics]

Okay, but if it’s not about money and the literature shows that large fraction sizes used in palliation are safe, then what is it? For example, read Candace Johnstone’s answer on TheMedNet about why people retreat more after single fraction. Has zero percent to do with efficacy or durability and anyone that says otherwise is doing it without data.

theMednet

t.co

I’m not saying people are using solely economic factors to determine fraction size for palliation. However, I have not seen one shred of evidence in favor of MFRT for bone mets. Plus, balance of data shows greater acute toxicity.

It’s not the doctor’s fault. It’s the system’s fault.

Ah, to be clear, I think money does have A LOT to do with it, don't get me wrong. It's just that, over the years, I have encountered (usually older) RadOncs who have a profound conviction about using the moderate hypofraction doses and normal tissue effects. I CERTAINLY do not agree with them, but the vehemence with which these beliefs are held is...surprising.

I agree with @TheWallnerus here, and while I recognize that Johnstone has been doing this a lot longer than I have (as have you, Simul), I disagree with her opinion in that MedNet post. Saying she's "wrong" is too strong - I think there is evidence to support her belief, but to definitively state that the belief that MFRT is more durable than SFRT is a "myth" is going a bit far in 2021 - though I am defining durability as local control, and I believe she is defining durability as pain response.

The review article @TheWallnerus linked above does, in my opinion, support the continued use of palliative MFRT in the appropriate clinical scenario. As before, I'll reference the cord compression literature:

I feel like this issue often gets painted in too broad of a stroke.

The rib met above is a great example. If that patient came to me in consult next week, I would think about it as follows:

1) If the patient is otherwise healthy and that rib met is an oligomet/oligoprogression, I would consider SBRT. Due to its size, I would probably go with 27/3 or 30/5 due to size and motion (errors average out!).

2) If it is not an oligomet and there's a high burden of disease, but the patient has a prognosis >6 months and otherwise has a high performance status, I would personally go with 30/10 using dynamic conformal arcs. Not only are DCAs still considered 3D, they're also still easy to plan and protect adjacent OARs better - but it's often cheaper for the patient than AP/PA, as you're technically only using one field instead of two (or more). Obviously, your mileage may vary with that statement based on who does your billing, but for me in my practice, it sometimes saves the patient money.

3) If it's not an oligomet and the prognosis is <6 months and/or the patient has a low performance status, I would absolutely use 8/1 or 20/5 (still using DCAs). I haven't dabbled with the 14/1 yet, because 8/1 usually works great and why fix what ain't broke.

For me, in this current era of SBRT and oligomets, this argument of MFRT vs SFRT is more nuanced than it was in the 2000s. To say there's no role for 30/10 anymore strikes me as somewhat radical, though I have literally heard "30 in 10 is dead" this year from the academicians.

With all the new systemic agents, oligomet data, and significantly improved ability to deliver any form of radiation compared to 20 years ago, there are so many factors to consider in palliative cases that I believe 30/10 is not "dead", just another tool in our arsenal. But I also believe in "getting cute" with palliative cases because each patient's case deserves to be considered thoroughly, and I know Boomer RadOncs hate "getting cute" with palliative cases.

 

[deleted1111261]

Long post ESE. I’m talking pain control and majority of ROs that don’t do SFRT are talking about pain control, too.

 

[elementaryschooleconomics]

I sent myself down a PubMed rabbit hole with that post (as I often do), and found this amazing paper published in July which really captures and codifies how I think about this.

Figure 5 is "just" a possible algorithm but I feel like it is a tremendous example of what we should be considering for palliative patients:

Long post ESE. I’m talking pain control and majority of ROs that don’t do SFRT are talking about pain control, too.

Agreed. I'm deviating from my normal SDN mission and derailing this thread.

I'm a huge fan of the RadOnc Twitter trend born this week of creating contouring playlists. I want to see more!

 

[TheWallnerus]

I have literally heard "30 in 10 is dead" this year from the academicians.

30/10 must not be totally dead because it’s the correct answer on at least one ABR OLA palliative question case currently, interestingly, shockingly?

I’m talking pain control and majority of ROs that don’t do SFRT are talking about pain control, too.

Figure 5 is "just" a possible algorithm but I feel like it is a tremendous example of what we should be considering for palliative patients:

Reminder: right or wrong, ASTRO/Choosing Wisely says single fraction assoc w/ higher re-tx rates.

Remind me @elementaryschooleconomics ... Have we rigorously defined "complicated" bone metastasis yet. Or is it like what Supreme Court Justice Potter Stewart used when defining pornography: "I know it when I see it."

 

[elementaryschooleconomics]

Have we rigorously defined "complicated" bone metastasis yet. Or is it like what Supreme Court Justice Potter Stewart used when defining pornography: "I know it when I see it."

The judicious use of retrospective studies, non-inferiority trials, and endpoints lacking rigorous operational definitions adds a wonderful flavor to the debate of the art of medicine!

It's why I like that cord compression paper, because they defined "local control" very reasonably (and while it's not randomized, it's prospective with >200 patients analyzed):

There are other papers published in the last 10 years showing the same thing (i.e. Abu-Hegazy 2011 with statistically significant worse 2-year in-field recurrence rates of 22.2% for 8/1 vs 16.1% for 30/10 and 13.5% for 40/20)

To me, choosing use "durability of pain control" as your endpoint for SFRT vs MFRT is fine if prognosis is <6 months, but I personally cannot disregard this data in considering a treatment scheme for someone who seems to have a prognosis >6 months.

Drilling down into Johnstone's MedNet post:

1) The 1998 Jeremic dose threshold paper she references is tangential to this discussion, but they elected to do all their analysis at 8 weeks (showing, arguably, that 8x1 is better than 4x1 or 6x1).

2) The 2014 Chow paper referenced is in regards to 20/5 vs 8/1 in the repeat XRT setting, and was (my favorite) a non-inferiority trial, and 8/1 was only found to be statistically non-inferior in the intention-to-treat analysis, NOT in the per-protocol analysis, and analysis was also done at 8 weeks. The authors do a great job in the discussion with this point - but I wouldn't be hanging my hat on a non-inferiority trial that has discordant statistical "significance".

In a reply to that MedNet post, she writes the following about endpoints:

I've read a lot of her work, and I believe she is talking about "uncomplicated" bone mets, which, as @TheWallnerus pointed out, lacks a strong definition, but "I know it when I see it". So yeah, if someone comes to my clinic as their last stop before enrolling on home hospice with a painful bone met in their left scapula, I will (and have previously) treat with 8x1, hopefully on the same day, or at least within 48 hours. But if it seems like prognosis is >6 months, and I don't elect SBRT for whatever patient-specific reason, I usually go with 30/10 (barring transportation issues etc). I guess these days, it's weird for me to see someone with something I would consider "uncomplicated" who I don't treat with SBRT...which is why I feel like this debate is growing increasingly outdated (which is great!!).

Sorry, I know this is another ridiculous post for the Twitter thread, and I don't want to come across as combative/argumentative. I'm a big fan of Dr Johnstone (and Simul), to be clear. I find this particular topic endlessly fascinating because "bone mets" is one of (if not the) most common things many of us see, and there are many folks with VERY strong opinions based more on anecdote than data. Then, when you try to drill down into these opinions, you are often hit with "don't get cute".

 

[RickyScott]

If pt is receiving first/second line systemic treatment for breast or prostate, I typically choose 300 x 10. If there is not much left systemically for patient, usually go with short course. Palliative xrt is over half my treatment. If I went exclusively to single fraction, hospital would start sending techs home early and we would loose the good ones.

 

[elementaryschooleconomics]

If pt is receiving first/second line systemic treatment for breast or prostate, I typically choose 300 x 10. If there is not much left systemically for patient, usually go with short course. Palliative xrt is over half my treatment. If I went exclusively to single fraction, hospital would start sending techs home early and we would loose the good ones.

Those of us in the community are also small cogs dependent on referrals. There is an expectation of "how things are done"; rock the boat too hard and the machine will find a new cog. To us, these debates of 10 vs 5 vs 1 fractions are filled with importance and and meaning, while to the majority of the rest of medicine, it's "hey are you done with radiation in one week or two" when they see a patient at a 3 month follow-up.

 

[Palex80]

If pt is receiving first/second line systemic treatment for breast or prostate, I typically choose 300 x 10. If there is not much left systemically for patient, usually go with short course. Palliative xrt is over half my treatment. If I went exclusively to single fraction, hospital would start sending techs home early and we would loose the good ones.

Well, we now have evidence that higher BED than 30/3 or 20/4 is beneficial in terms of pain and local control. Do you see any chance of going for some sort of SBRT (doesn't need to be single fraction),

 

[temujim]

Well, we now have evidence that higher BED than 30/3 or 20/4 is beneficial in terms of pain and local control. Do you see any chance of going for some sort of SBRT (doesn't need to be single fraction),

For whatever reason I have thyroid met pipeline. Gave up on 30/10 or 8/1 a while ago. SBRT just about everything now for those patients. Has become almost default for the rest too. Haven't heard any squawks from the insurance companies... yet.

 

[RickyScott]

Well, we now have evidence that higher BED than 30/3 or 20/4 is beneficial in terms of pain and local control. Do you see any chance of going for some sort of SBRT (doesn't need to be single fraction),

Hard to get sbrt approved and physics and dosimetry take excessively long for planning..

 

[Reaganite]

Those of us in the community are also small cogs dependent on referrals. There is an expectation of "how things are done"; rock the boat too hard and the machine will find a new cog. To us, these debates of 10 vs 5 vs 1 fractions are filled with importance and and meaning, while to the majority of the rest of medicine, it's "hey are you done with radiation in one week or two" when they see a patient at a 3 month follow-up.

Straight up. I still receive calls from urologists when I do 28 fraction prostate and breast surgeons/oncs still tell every pt breast xrt is 6 weeks. First question is always "is that safe". Then when you tell them about the studies it's "why would your field do these studies if you're paid by the fraction?"

 

[deleted1111261]

For whatever reason I have thyroid met pipeline. Gave up on 30/10 or 8/1 a while ago. SBRT just about everything now for those patients. Has become almost default for the rest too. Haven't heard any squawks from the insurance companies... yet.

This is what I think should be the path. Vmat/Sbrt for pain control and local control. 1-3 fractions, maybe 5 in certain scenarios.

People have this idea that I’m a “value-based” zealot. Value means many things. My “value” of 1 vs 10 fx is the time cost for the patient, not the expense. I am pro site neutral and “APM” style payments but not RO-APM. I don’t think we should use less technology. We should use the optimal approach. Image guidance to reduce PTV and avoid miss? Yes please. Conformal treatments to give 14-16 Gy to a met in one day? Yes please. VMAT + IGRT + DIBH to treat partial breast? Yes, please. VMAT for anything that requires contouring of targets and decreasing dose to you know important organs like lung, heart, bowel? Yes, please.

“Get your government out of my Medicare” 😂 but yah, let me treat my patients the right way. 1 vs 10 for bone mets divides us. Yeah, I’m pro single fraction, but I’m anti complex isodose and using ports when we have the resources to do better.

 

[Lamount]

I love SBRT for small bone mets in optimal locations… and 8 Gy x 1 for the pt with the aggressive cancer or low PFS

…but if I have had a few acetabular oligomets for RCC/ACC recently, and didn’t feel right about 8-16 Gy X 1 or 9 Gy x 3. In both of these cases, I did 4 Gy x 10 to spare the joint capsule (limited to 3.5 Gy x 10. I can’t cite data, but 8 Gy x 1 felt like under treatment… and 9 Gy x 3 seemed too toxic to hip.

…it’s all case-by-case.

 

[madchemist89]

There is no point arguing fervently over the difference between 1,5, and 10 treatments for bone mets. The difference between these different regimens is almost immaterial. Our effort is better spent elsewhere. Each fractionation has its use depending on the situation.

 

[medgator]

There is no point arguing fervently over the difference between 1,5, and 10 treatments for bone mets. The difference between these different regimens is almost immaterial. Our effort is better spent elsewhere. Each fractionation has its use depending on the situation.

Bingo, but it seems to really trigger the ultra hypo-fractionators/fraction shamers out there.

It's like "where did the bad 10 fraction regimen touch you, bro?"

 

[elementaryschooleconomics]

There is no point arguing fervently over the difference between 1,5, and 10 treatments for bone mets. The difference between these different regimens is almost immaterial. Our effort is better spent elsewhere. Each fractionation has its use depending on the situation.

 

[RickyScott]

There is no point arguing fervently over the difference between 1,5, and 10 treatments for bone mets. The difference between these different regimens is almost immaterial. Our effort is better spent elsewhere. Each fractionation has its use depending on the situation.

You would not be accredited by the upenn palliative care network.