The current standard of care for Limited SCLC

[Gfunk6]

Outside of a clinical trial, is everyone still using Turrisi's b.i.d. regimen?

I haven't seen any data from CALGB 30610.

---

Members don't see this ad.

 

[medgator]

Outside of a clinical trial, is everyone still using Turrisi's b.i.d. regimen?

I haven't seen any data from CALGB 30610.

I think in the community, a lot of people treat QD to 60-70 Gy (A 2003 patterns of care study citied in the CALGB protocol found that <10% of pts got Turrisi while 80% QD XRT). There is data suggesting that 70 Gy with chemo is tolerated well

http://www.ncbi.nlm.nih.gov/pubmed/15145163?dopt=Abstract

Part of the impetus for creating the intergroup trial (CALGB 30610/RTOG 0538) which compares Turrisi to QD to 70 Gy is the issue you're asking. Turrisi is what is proven, but it was compared against 45 Gy QD (which is not a high enough dose), while most people aren't doing either in the real world

 

[ShirleyT]

I usually do 45 Gy bid. If the patient absolutely cannot do bid for some reason, I will do 60 Gy at 2 Gy per fraction.

 

[alphacentauri]

I think Turrisi is still the standard of care outside a clinical trial if the patient can handle coming in twice daily. I try to enroll all my LS-SCLC pts on CALGB 30610 if eligible. If they aren't eligible I suggest 45/1.5 bid, but if they won't or can't do it, I'll offer 60-66 in 2 Gy fractions QD. Pts from the community that I've seen seem to usually receive QD regimens though. The CALGB data will be really interesting once available.

 

[deleted4401]

In our community practice, BID always offered. If they refuse, 60ish Gy qD.
Funny about patients not being amenable. They have a life threatening disease. We have a van service. Just come twice a day, enough with the whining already.

On the other hand, doubt BID will be better than other arms on that trial, but I do want to know and until then, BID is SOC.

 

[TarHeelRadOnc]

I do 45/30 BID whenever possible. Practice in a smaller town that draws from a large rural area, so some patients can't do BID with 6hr interfx interval, in which case I do 60/30 qday.

 

[medgator]

I do 45/30 BID whenever possible. Practice in a smaller town that draws from a large rural area, so some patients can't do BID with 6hr interfx interval, in which case I do 60/30 qday.

I tell them the option as well, and go to 66/33 if they elect for QD over BID

 

[medgator]

Funny about patients not being amenable. They have a life threatening disease. We have a van service. Just come twice a day, enough with the whining already.
.

Sorry to sidetrack this, but I really want to know.....

Are there any issues with that? I've heard that it can run into ethical problems if you provide transportation for patients to and from XRT. We typically refer patients to our local chapter of the ACS for assistance with either gas cards or a volunteer driver.

 

[deleted4401]

I don't know how it works. I know that our physics company employs the van driver, and although we are not partners with them, we are involved with a corporation that includes them and the hospitals. Their fear of liability is far greater than mine, so presuming it has been vetted solidly. If they are a smidgen sick or need to picked up any where that is not their house, we don't do it.

We really have to do it. It's too difficult for our rural patients.

 

[Palex80]

We do 45/1.5 bid whenever possible. If we can't treat like that, we usually give 54-60/2.

I am not certain if dose escalation to 70 Gy is right way to go and I am anxious to see how patients in the CALGB trial will do. I suspect higher rates of pneumonitis with 70/2. It's tough to achieve acceptable lung constraints if you are treating extensive N2 or N3 LD-SCLC with 70/2 in my opinion.

 

[Newquagmire]

CONVERT trial results released:
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(17)30318-2/fulltext

"At a median follow-up of 45 months (IQR 35–58), median overall survival was 30 months (95% CI 24–34) in the twice-daily group versus 25 months (21–31) in the once-daily group (hazard ratio for death in the once daily group 1·18 [95% CI 0·95–1·45]; p=0·14). 2-year overall survival was 56% (95% CI 50–62) in the twice-daily group and 51% (45–57) in the once-daily group (absolute difference between the treatment groups 5·3% [95% CI −3·2% to 13·7%]). The most common grade 3–4 adverse event in patients evaluated for chemotherapy toxicity was neutropenia (197 [74%] of 266 patients in the twice-daily group vs 170 [65%] of 263 in the once-daily group). Most toxicities were similar between the groups, except there was significantly more grade 4 neutropenia with twice-daily radiotherapy (129 [49%] vs 101 [38%]; p=0·05). In patients assessed for radiotherapy toxicity, was no difference in grade 3–4 oesophagitis between the groups (47 [19%] of 254 patients in the twice-daily group vs 47 [19%] of 246 in the once-daily group; p=0·85) and grade 3–4 radiation pneumonitis (4 [3%] of 254 vs 4 [2%] of 246; p=0·70). 11 patients died from treatment-related causes (three in the twice-daily group and eight in the once-daily group)."

 

[Palex80]

Bearing in mind that the trial was designed to prove SUPERIORITY of the 66/2 arm over the 45/1.5 bid arm, this trial is not only negative. It also shows that 45/1.5 just might even be SUPERIOR to 66/2 (although not reaching statistical significance).

It's "just" a 5% difference in OS, but bear in mind that in LD-SCLC the 25% survival à la Turrissi is based on 5 x 5% OS-benefit:
1. 5% by giving RT at all
2. 5% by delivering RT together with CT and not sequential
2. 5% through early RT during CT
3. 5% through hyperfractionation-acceleration
4. 5% through PCI

Points 1-5 have been proven (more or less) in randomized trials in the past.

 

[medgator]

Interesting, but I await the results of rtog 0538 before we can say for sure that bid is preferred imo. Maybe 70Gy is the magic number and we have to treat sclc to a higher dose than nsclc (!!!)

The standard arm in the turrisi small cell study was not a standard of care and did not prove that 45 Gy bid was the preferred approach. Logistically,, it is difficult for some patients to do it as well as for providers who cover two part time clinics a day

 

[seper]

I've found that b.i.d vs. q.d. choice is very easy to make. Most patients will have very strong preference to one or another due to social situation and driving distance.

 

[John Rattan]

Interesting, but I await the results of rtog 0538 before we can say for sure that bid is preferred imo. Maybe 70Gy is the magic number and we have to treat sclc to a higher dose than nsclc (!!!)

The standard arm in the turrisi small cell study was not a standard of care and did not prove that 45 Gy bid was the preferred approach. Logistically,, it is difficult for some patients to do it as well as for providers who cover two part time clinics a day

Is that right? What was the standard of care at that time? Every SWOG study was using 40-50. CALGB was using 40 Gy. Every NCIC trial, the Danes, the pre-Brexit Brits, and the Dutch were all using 40 - 45 Gy. The only one doing more was that damn Yugoslav, Jeremic, who gave 54 in 1.5 Gy BID. The average dose was 45 Gy. What do you believe the standard of care was at that time? What in the world are you talking about?

 

[OTN]

Is that right? What was the standard of care at that time? Every SWOG study was using 40-50. CALGB was using 40 Gy. Every NCIC trial, the Danes, the pre-Brexit Brits, and the Dutch were all using 40 - 45 Gy. The only one doing more was that damn Yugoslav, Jeremic, who gave 54 in 1.5 Gy BID. The average dose was 45 Gy. What do you believe the standard of care was at that time? What in the world are you talking about?

At the time it may have been the standard of care, but I think it's pretty realistic to say now that 45 Gy delivered daily for definitive treament of most carcinomas is too low.

 

[John Rattan]

At the time it may have been the standard of care, but I think it's pretty realistic to say now that 45 Gy delivered daily for definitive treament of most carcinomas is too low.

So, how do you do a phase III trial on dose in SCLC in 1990? Come up with some predicted future qD dose that no one is using and make that your standard arm? That would be a phase II RCT. I don't understand what poor AT3 was supposed to do. From my understanding, the standard of care arm should reflect the current standard of care. Otherwise, it wouldn't be standard of care.

 

[Palex80]

The whole "driving" argument is partially an argument, in my humble opinion.

66/2 means driving 33 times to the clinic.
45/1.5 bid means driving 30 times to the clinic.

Sure, you don't have to do it on a daily basis, but in the end the patient spends more or less the same time in the car.
Add to that the fact that on one of the three weeks of the bid schedule the patient is getting chemo anyways and would have to stay for quite some time in the clinic either on an inpatient or outpatient basis.

 

[nkmiami]

Majority of my patients dont want bid. If the volume is on the small side and I can spare esophagus, I have done 45 Gy in 15 treatments, otherwise I usually go to 60 in 28-30 fractions. The intergroup fields were much bigger than what is used today.

 

[medgator]

Is that right? What was the standard of care at that time? Every SWOG study was using 40-50. CALGB was using 40 Gy. Every NCIC trial, the Danes, the pre-Brexit Brits, and the Dutch were all using 40 - 45 Gy. The only one doing more was that damn Yugoslav, Jeremic, who gave 54 in 1.5 Gy BID. The average dose was 45 Gy. What do you believe the standard of care was at that time? What in the world are you talking about?

The standard of care at the time wasn't a "modern" standard of care which is why you won't find 40-50 Gy QD in any guidelines, including the nccn, or in the current intergroup calgb/rtog study. Sorry but your argument doesn't hold water considering one of the arms has not been a SOC in this century.

With that logic, you could pretty much treat your intermediate risk prostate patients to 70 Gy as long as you give them some lupron since that was a standard of care at one point in an RCT and was shown to be of benefit

 

[John Rattan]

The standard of care at the time wasn't a "modern" standard of care which is why you won't find 40-50 Gy QD in any guidelines, including the nccn, or in the current intergroup calgb/rtog study. Sorry but your argument doesn't hold water considering one of the arms has not been a SOC in this century.

With that logic, you could pretty much treat your intermediate risk prostate patients to 70 Gy as long as you give them some lupron since that was a standard of care at one point in various comparative studies and was shown to be of benefit

The trial was written in 1989. What are you telling me the standard dose of RT was in 1989?

If you are doing a trial in 2017, you can say that doing a qD to 45 would be non-standard. In 1989, everyone was giving between 40-50. You keep saying that was not standard of care. What was the standard of care dose in 1989?

Your exact quote is that "the standard arm was not standard of care". But, in fact, it specifically was standard of care. If you read a textbook in 1989, the dose recommended would be 40-50 Gy.

 

[seper]

I've worked in urban hospitals all my career, and majority of patients I treat actually want b.i.d. These are either unemployed ones who live within walking distance, or regular urban dwellers who catch the bus/Uber. Being done in 3 weeks appeals to them.

Majority of my patients dont want bid. If the volume is on the small side and I can spare esophagus, I have done 45 Gy in 15 treatments, otherwise I usually go to 60 in 28-30 fractions. The intergroup fields were much bigger than what is used today.

 

[napoleondynamite]

I've worked in urban hospitals all my career, and majority of patients I treat actually want b.i.d. These are either unemployed ones who live within walking distance, or regular urban dwellers who catch the bus/Uber. Being done in 3 weeks appeals to them.

It's all in how you sell it to the patient. I have never had a patient tell me know on BID, but it's because I'm a strong believer so far. So I twist arms and I'm batting 1000.

 

[medgator]

Your exact quote is that "the standard arm was not standard of care". But, in fact, it specifically was standard of care. If you read a textbook in 1989, the dose recommended would be 40-50 Gy.

I should have said "is"

 

[John Rattan]

If my intuition is correct, most studies written nearly 30 years ago have a standard arm that is no longer the modern standard, yet that does not discredit the results of the trial.

 

[John Rattan]

It's all in how you sell it to the patient. I have never had a patient tell me know on BID, but it's because I'm a strong believer so far. So I twist arms and I'm batting 1000.

Exactly. Batting 1.000, as well.

Majority of my patients dont want bid. If the volume is on the small side and I can spare esophagus, I have done 45 Gy in 15 treatments, otherwise I usually go to 60 in 28-30 fractions. The intergroup fields were much bigger than what is used today.

I like 45/15 and wonder when that study gets published (comparing 45/30/BID vs 45/15/qD).

 

[Burt Radnolds]

I don't understand what poor AT3 was supposed to do.

So, uhhh, we're just letting that one slide?

 

[medgator]

If my intuition is correct, most studies written nearly 30 years ago have a standard arm that is no longer the modern standard, yet that does not discredit the results of the trial.

You're right. 45 Gy given BID is > 45 Gy QD. Does that mean that 45 Gy BID is now the standard of care since it was studied in a randomized fashion against an arm no one in their right mind would ever treat on in the last 15 years? 6 months of lupron confers a survival benefit with 70 Gy vs 70 Gy alone in prostate cancer.... is that how you treat your prostates assuming you aren't SBRTing everyone that comes through the door?

 

[RadOncDoc21]

So, uhhh, we're just letting that one slide?

Has a nice ring to it... hopefully he has better knee joints than RG3

 

[John Rattan]

So, let's tell a little story about how evidence-based medicine works.

1. We have a disease that has a standard treatment. The treatment does not cure 100% of people, in fact it doesn't cure 20% of the people. So, really smart people decide that it would be in patients' interest to develop a new and better treatment.

2. We have smart people doing lab studies and then clinical studies and then this leads to a phase 2 study that shows that a new treatment, appears to be superior to the previous treatment, when comparing to historical outcomes.

3. These smart people submit a study to an IRB, a phase 3 study comparing the standard of care (which was boringly named 'A') with the new and better and more exciting treatment (which the marketing department deftly chose to call 'B')

4. The trial is approved and completed. The pointy headed scientists were right, treatment B was better. BOOMER LIVES!

5. Now, treatment B is the arm that all future treatments should be compared to.

So, what you're saying is that EBM is a garbage approach and we should use whatever willy-nilly treatment schemes that sound better? Because it's a "modern standard". Based on what? Based on what study from the past (randomized) has 60-70 Gy been shown to be equivalent or superior to 45 Gy/BID to make its a "modern standard"? You keep saying 45 Gy qD is not standard. Agreed - see above - AT3 and his motley crew proved it so. So, we have a standard of care. 45 Gy/30 fx/BID with cis/etop x 4 followed by PCI.

Now, it sounds like the best radiation oncologist in Florida (a little like being the Governor of Alaska) is huffing and puffing and saying some dose between 60-70 Gy is better. So, what happens? Some blokes from the UK decide to do a study, in a very similar fashion as the one above. The saw the standard arm - 45 Gy/30fx/BID still didn't cure 70% of the people. They had an idea that a higher BED could improve the >50% local failure seen in the BID (which makes sense). They did the studies and showed efficacy. Then, submitted a trial saying that it would be better than the control arm. In fact, they powered the trial to show a 12% benefit for qD treatment.

And what did we find? The qD arm did 5% worse than expected. The BID arm did 12% better than expected. It's not statistically significant, but it's 5% better and definitely not worse. Plus 11% less grade 4 neutropenia. Do you know what grade 4 neutropenia is? I didn't f**ckin' know, so I looked it up. It means 11% more people had ANC < 500. THAT SUCKS, man. You can have your 66 Gy/33 fx qD, buddy.

It's interesting that certain people always support the the treatment that leads to the highest reimbursement in a fee for service model (hypofractionation for breast, although seems like people are 'evolving', prostate HF, spinal cord compression, and now this).

 

[medgator]

It's not statistically significant

/Thread

But then you had to keep talking.....

Plus 11% less grade 4 neutropenia. Do you know what grade 4 neutropenia is? I didn't f**ckin' know, so I looked it up. It means 11% more people had ANC < 500. THAT SUCKS, man. You can have your 66 Gy/33 fx qD, buddy.

Ok Mr Kaiser Permanente. It seems like you don't want to work as hard to give 3 extra fractions, but it would behoove you to read the actual study from the Lancet. You have your figures reversed. Grade 4 neutropenia was WORSE in the BID arm by 11% which was in fact SS

It's interesting that certain people always support the the treatment that leads to the highest reimbursement in a fee for service model (hypofractionation for breast, although seems like people are 'evolving', prostate HF, spinal cord compression, and now this).

30 fractions vs 33 fractions..... big whoop. Don't hurt yourself working til 445 instead of 430 to give 3 extra fractions to the patient... I know you won't be compensated for it any differently, but at least think about their ANC.

 

[Burt Radnolds]

Plus 11% less grade 4 neutropenia. Do you know what grade 4 neutropenia is? I didn't f**ckin' know, so I looked it up. It means 11% more people had ANC < 500. THAT SUCKS, man. You can have your 66 Gy/33 fx qD, buddy.

Most toxicities were similar between the groups, except there was significantly more grade 4 neutropenia with twice-daily radiotherapy (129 [49%] vs 101 [38%]; p=0·05).

I can't read very well and have trouble understanding fancy statistics, but I feel you may have contradicted yourself? Someone smarter than me please reconcile the above two statements.

Also, this trial is basically negative and to me only proves that Qday is likely not any better, but not necessarily worse. No outcomes outside of the above mentioned grade 4 neutropenia, which the monkey behind the wheel in my brain is telling me was actually worse in the BID arm, were significant. The non-significant 5% difference in survival between the two arms is, how do we say it, thought provoking? hypothesis generating?, but ultimately meaningless to me given it did not satisfy any preset statistical endpoints put forth in the study.

As the study says in its conclusion, "the implication is that twice-daily radiotherapy should continue to be considered the standard of care in this setting", which I can agree with, given that it has the best phase 1 data supporting it. We will have to await the CALGB/RTOG study results to potentially prove otherwise. I do not feel that those offering 60-70 Qday are committing malpractice however, and that approach is clearly endorsed in NCCN guidelines, for whatever that is worth.

 

[John Rattan]

I sure did bungle that one!

/Thread

But then you had to keep talking.....



Ok Mr Kaiser Permanente. It seems like you don't want to work as hard to give 3 extra fractions, but it would behoove you to read the actual study from the Lancet. You have your figures reversed. Grade 4 neutropenia was WORSE in the BID arm by 11% which was in fact SS




30 fractions vs 33 fractions..... big whoops. Don't hurt yourself working til 445 instead of 430 to give 3 extra fractions to patient... I know you won't be compensated for it any differently, but at least think about their ANC.

 

[medgator]

As the study says in its conclusion, "the implication is that twice-daily radiotherapy should continue to be considered the standard of care in this setting", which I can agree with, given that it has the best phase 1 data supporting it. We will have to await the CALGB/RTOG study results to potentially prove otherwise. I do not feel that those offering 60-70 Qday are committing malpractice however, and that approach is clearly endorsed in NCCN guidelines, for whatever that is worth.

JR reversed the figures because he wants to hypo-fractionate anything he can it seems (maybe he works at KP, VA, who knows?). The grade 4 neutropenia was statistically significantly worse in the BID arm by a double-digit percentage. Hardly re-assuring that BID is the unquestionable SOC. Which is why we have an ongoing intergroup trial to address this question. The ANC issue makes me feel comfortable continuing to offer both treatments to my patients when logistically possible, but it almost makes me feel better offering QD.

I am surprised about the esophageal toxicity being similar between the groups because, in my experience, I've found esophagitis to be worse in BID patients.

 

[napoleondynamite]

Esophagitis - valid point. I've trudged ahead with patients, valiantly feeling that I would not kill them with kindness, believing in the BID data and that the esophagitis was a cost worth paying. But I am willing to change! I would love to be convinced on the QD data and transition that way. I think it's easier on everyone. I'm just not sure we are there yet until we have the results from the CALGB study.

But does anyone actually believe the grade 4 neutropenia would be related to BID vs QD radiation?

 

[mavrik13]

But does anyone actually believe the grade 4 neutropenia would be related to BID vs QD radiation?

This seems like a classic type 1 error - spurious findings do occur, and the mechanism of radiotherapy seems unlikely to contribute to neutropenia.

Interesting study. We tend to use 60/30 or 45/30 BID, with 40/15 being a third option if borderline PS (very common in Canada).

 

[Palex80]

Turrisi-style treatment is like being hit by truck in the middle of the highway. You don't what hit you, until after it happened...
I personally like it and in my experience this tough, short, aggressive treatments generally lead to higher compliance rates than the prolonged fractionation schedules we sometimes use.
I haven't seen a single breast patient complaining about dermatitis with 39.9/2.66, since if it is to happen, it happens AFTER they are done with treatment.
The same applies to concomitant boost hyperfractionation in head and neck cancer. The first three weeks (qD) go well, then you get into the BID-schedule and mucositis startsrising but most of the patients are like "Oh, it's just 2 more weeks of treatment, I'll be fine". By the time mucositis hits °III, they are almost done with treatment anyway... They do need quite some time to recover from it, but you got your dose in. Mission accomplished.

 

[Reaganite]

Turrisi-style treatment is like being hit by truck in the middle of the highway. You don't what hit you, until after it happened...
I personally like it and in my experience this tough, short, aggressive treatments generally lead to higher compliance rates than the prolonged fractionation schedules we sometimes use.
I haven't seen a single breast patient complaining about dermatitis with 39.9/2.66, since if it is to happen, it happens AFTER they are done with treatment.
The same applies to concomitant boost hyperfractionation in head and neck cancer. The first three weeks (qD) go well, then you get into the BID-schedule and mucositis startsrising but most of the patients are like "Oh, it's just 2 more weeks of treatment, I'll be fine". By the time mucositis hits °III, they are almost done with treatment anyway... They do need quite some time to recover from it, but you got your dose in. Mission accomplished.

I think your post actually highlights a key issue I have had to deal with on the private practice/keeping patients and referring doctors happy side. Many of these accelerated regiments have side effects that show up after patient has completed treatment. Maybe I'm in the minority here, but my patients hate accelerated treatment. Every single patient I've treated for breast has complained about the delayed skin reaction and several of them have gone to the er for an "infection " that showed up after radiation. Doesn't matter how much I tell them they will get a delayed reaction they just can't wrap their brains around the fact reaction will show up after the treatment is done. I have even had referring physicians call me and tell me not to do short course treatment for this very reason...too many patient complains. Are you guys seeing anything like this with the turrisi regimen, particularly the esophagitis?

 

[Burt Radnolds]

You reopened the can of worms so here we go... Regarding breast cancer, up front, I describe the historical context of conventional vs hypofractionation and the major phase 3 trials involved, including the potential toxicity differences. Patients profusely thank me for not bilking them out of cash, time, and for allowing them to potentially benefit from improved cosmesis. I treat 95% of my tangential patients with hypofractionation. The data is too compelling to do otherwise. Are you religiously using 6MV only? If I have any suspicion of a bad skin reaction, I will see them in 1-2 week follow up to reassure. I work in pure physician owned private practice BTW.

Also fwiw, I am not a hardcore adopter of hypofractionation of other sites, I just see the data how I see it. Prostate is still very up in the air and I respect the argument that toxicity may be higher in some hypofx situations. SCLC is also not currently a slam dunk and I see the merits of qday vs BID. Breast tangents however.... Data is too strong. START B 4 life.

 

[medgator]

You reopened the can of worms so here we go... Regarding breast cancer, up front, I describe the historical context of conventional vs hypofractionation and the major phase 3 trials involved, including the potential toxicity differences. Patients profusely thank me for not bilking them out of cash, time, and for allowing them to potentially benefit from improved cosmesis. I treat 95% of my tangential patients with hypofractionation. The data is too compelling to do otherwise. Are you religiously using 6MV only? If I have any suspicion of a bad skin reaction, I will see them in 1-2 week follow up to reassure. I work in pure physician owned private practice BTW.

Also fwiw, I am not a hardcore adopter of hypofractionation of other sites, I just see the data how I see it. Prostate is still very up in the air and I respect the argument that toxicity may be higher in some hypofx situations. SCLC is also not currently a slam dunk and I see the merits of qday vs BID. Breast tangents however.... Data is too strong. START B 4 life.

Agreed with everything you've said. The data for breast is most compelling compared to prostate or sclc. Randomized data actually favors hypofx for decreasing acute side effects:

Acute and Short-term Toxic Effects of Fractionated Breast Irradiation

In addition to possible improved cosmesis.

I get where reaganite is coming from in terms of side effects showing up after they complete treatment, but imo, the solution I've found is a 1 week to 1 month skin check prn. I've told my patients to call me at any point and come in if anything is up with their skin after they complete treatment.

 

[Phantom1]

Awesome thread! Classic Turrisi Battle!!

I'll throw in my 2 cents..

Although 45Gy QD was SOC at the time when viewed today it was a weak control arm, thus the magnitude of 45Gy BID remained in question. 45Gy BID certainly caused more esophagitis in original study compared to QD for main reason that 45Gy BID is higher BED than 45 QD! The CONVERT trial was really really well done and the conclusions are plainly and well stated. There was less esophagitis primarily because the large elective nodal Turrisi fields were not used or permitted. More importantly there was no significant difference in esophagitis between the groups! Thus the long standing and anecdotal statement: "I see more esophagitis with 45BID.." is in my view is entirely debunked, as COVERT was a huge trial with 547 patients (~274 patients in each randomized arm) and showed exactly the same rates of esophagitis. The only real difference in side effects was the neutropenia, which itself is an interesting issue and maybe points to the issue of how fast the hematopoietic cells can respond to chemo and radiation insult, perhaps the QD dosing gives a little more time for myeloid progenitors to expand out to generate more neutrophils?? Irregardless, the survival was slightly and non-significantly increased, thus this neutropenia did not impair survival compared to QD

As the authors stated it was a superiority trial which did not meet its primary endpoint, and thus the "experimental arm" (66/33fx QD) was not proven superior to the BID dosing. There is a preponderance of data (as the authors reference in their discussion) that treatments with an overall shorter treatment time seem to result in slightly better outcomes than longer duration treatments, especially for rapidly cycling tumors, such as small cell, head and neck, cervical, etc. Thus as demonstrated in this large Phase III randomized study the BID dosing appears to result in slightly better survival than the QD longer course.. Really interesting stuff! I think if I were a patient with limited stage NSCLC I would want to have the BID dosing....

 

[Palex80]

I think if I were a patient with limited stage SCLC I would want to have the BID dosing....

Very well put!
I'm pushing individual patients with N1 & low-volume N2 disease to 54 bid with adaptive planning during RT. There is a tiny Japanese single-arm trial showing promising results.

 

[Ray D. Ayshun]

Is comparing the Turrisi survival data to the Convert trial data comparing apples to oranges a little? Turrisi was significant at 5 years, but I believe non-significant at 2. Though there is a non-significant difference at 2 in the Convert trial, 45 bid is numerically superior thus far and in the long-run may still win out.

 

[John Rattan]

I didn't reverse the figures because I want to hypofractionate everything. I reversed them because I'm a silly and am embarrassed about that. Whoa, bro. But, I'm taking to you, who as of a few days ago refused to hypofractionate DCIS because ASTRO said no, so I'm less of a silly than you. 6 weeks for non cancer and 3 for cancer ? Whoa, bro.

Esophagitis always happens after BID is done, for me, gotta get em in for 1 week follow up. How would you know if esophagitis happens more if you are always doing qD? It's hard to see the difference when you don't do it. And you don't like seeing global follow ups cause they don't pay. If you are okay with 5% less survival, that's fine with me, because Floridians don't deserve optimal treatment.

For breast, it's no question, you may get a nasty reaction one time with HF, but the data and the reality suggest that 61 Gy is worse than 52 Gy. I.e. Same person would have gotten same or worse reaction with longer treatment.

AT34LYFE

JR reversed the figures because he wants to hypo-fractionate anything he can it seems (maybe he works at KP, VA, who knows?). The grade 4 neutropenia was statistically significantly worse in the BID arm by a double-digit percentage. Hardly re-assuring that BID is the unquestionable SOC. Which is why we have an ongoing intergroup trial to address this question. The ANC issue makes me feel comfortable continuing to offer both treatments to my patients when logistically possible, but it almost makes me feel better offering QD.

I am surprised about the esophageal toxicity being similar between the groups because, in my experience, I've found esophagitis to be worse in BID patients.

 

[medgator]

oBut, I'm taking to you, who as of a few days ago refused to hypofractionate DCIS because ASTRO said no, so I'm less of a silly than you. 6 weeks for non cancer and 3 for cancer ? Whoa, bro.

Fake news... I've got someone under beam now getting it for dcis.

And you don't like seeing global follow ups cause they don't pay.

see above. I even gave my personal advice above about seeing hypofx breast <90 days out.

Don't project your bitterness about seeing global follow-ups to me

AT34LYFE

Youve got way too much time with your KP/VA gig... But surprisingly, your fake news needs work.

Honestly though you're probably better off finding a real hobby rather than trolling sdn and misquoting randomized studies... hopefully wherever you are affords something to take your mind off all that Florida-hatin' jealousy...

 

[John Rattan]

SDN, the city, the nation, and God thank you for putting A patient with DCIS "under beam" (what a weenie, ameritech?) under standard of care.

Appreciate you joining the 21st Century!

 

[John Rattan]

Very well put!
I'm pushing individual patients with N1 & low-volume N2 disease to 54 bid with adaptive planning during RT. There is a tiny Japanese single-arm trial showing promising results.

Are you just not going to link the trial?

 

[John Rattan]

DCIS - a disease that many say shouldn't be treated, but medgator says should be treated with 6 weeks of RT, and has pride to say he has one "under beam" getting 3 weeks. Rad onc should give him a medal.

Fake news... I've got someone under beam now getting it for dcis.

see above. I even gave my personal advice above about seeing hypofx breast <90 days out.

Don't project your bitterness about seeing global follow-ups to me



Youve got way too much time with your KP/VA gig... But surprisingly, your fake news needs work.

Honestly though you're probably better off finding a real hobby rather than trolling sdn and misquoting randomized studies... hopefully wherever you are affords something to take your mind off all that Florida-hatin' jealousy...

 

[medgator]

SDN, the city, the nation, and God thank you for putting A patient with DCIS "under beam" (what a weenie, ameritech?) under standard of care.

Appreciate you joining the 21st Century!

You still treat your prostates to 70 Gy with Lupron since there was an OS benefit to lupron in a RCT? Maybe you need to do the same...

 

[Gfunk6]

Sadly, this thread has degenerated from open exchange of ideas to personal attacks.

I think it has run its course . . . closing.


Sent from my iPhone using SDN mobile